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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197493099
Report Date: 07/29/2022
Date Signed: 07/29/2022 06:00:30 PM


Document Has Been Signed on 07/29/2022 06:00 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245



FACILITY NAME:HUMBLE HEARTS ACADEMYFACILITY NUMBER:
197493099
ADMINISTRATOR:AMANDA FRYFACILITY TYPE:
850
ADDRESS:13325 HAWTHORNE BLVD.TELEPHONE:
(424) 209-2537
CITY:HAWTHORNESTATE: CAZIP CODE:
90250
CAPACITY:39CENSUS: 21DATE:
07/29/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Phylisha WrightTIME COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst (LPA), V. Wheatley conducted a case management inspection at 3PM and met with licensee Phylisha regarding a child that wandered out of the facility through the front door and down an alley on July 11, 2022.

The child was found unharmed by Staff #2 with a female passerby. The licensee reported the incident on July 11, 2022 by telephone to CCL and submitted LIC 624 Unusual Incident form to the Department. Licensee conducted her own investigation and terminated Staff #1.

Today, LPA interviewed Staff #1, #2, #3, #4, #5 and the child's parent regarding the incident. The child returned to the facility after the incident.

The facility is cited for Lack of Supervision and assessed a civil penalty of $500. See LIC 9099D.


Exit interview and report provided to the licensee today.
SUPERVISOR'S NAME: Maureen NealTELEPHONE: (424) 301-3042
LICENSING EVALUATOR NAME: Veronica WheatleyTELEPHONE: (424) 301-3051
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/29/2022 06:00 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245


FACILITY NAME: HUMBLE HEARTS ACADEMY
FACILITY NUMBER: 197493099

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/01/2022
Section Cited

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101229(a)(1)-Responsibility for Providing Care and Supervision-(a) The licensee shall provide care and supervision as necessary to meet the children's needs.(1) No child(ren) shall be left without the supervision of a teacher at any time. Supervision shall include visual observation.
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This was evidenced by the Licensee / staff failed to supervised Child #1 as he was able to wandered out of the facility through the front door and down an alley on July 11, 2022. This is a risk to the heatlh and safety of children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Maureen NealTELEPHONE: (424) 301-3042
LICENSING EVALUATOR NAME: Veronica WheatleyTELEPHONE: (424) 301-3051
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2022
LIC809 (FAS) - (06/04)
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