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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494430
Report Date: 03/23/2021
Date Signed: 03/23/2021 03:26:34 PM

Document Has Been Signed on 03/23/2021 03:26 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:SHORT AVE ELEMENTARY SCHOOLFACILITY NUMBER:
197494430
ADMINISTRATOR:AMATO, VERONICAFACILITY TYPE:
840
ADDRESS:12814 MAXELLA AVETELEPHONE:
(310) 975-8524
CITY:LOS ANGELESSTATE: CAZIP CODE:
90066
CAPACITY: 40TOTAL ENROLLED CHILDREN: 40CENSUS: 0DATE:
03/23/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Applicant - Korey KalmanTIME COMPLETED:
02:20 PM
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On 03/23/2021 at 2:00pm Licensing Program Analyst (LPA) Ericka Hill conducted a Pre-Licensing visit with the Applicant via tele-visit due to COVID-19 restrictions and that this after-school-age program is located on a elementary school campus. LPA Hill spoke with both the Applicant, Korey Kalman, and their Consultant, Robert O'Connor.

During today's tele-visit, LPA observed the areas related to the after-school child care program which included: Classroom #17, the boy and girl bathrooms, and the outdoor play area.

In classroom #17 LPA observed school-age appropriate materials for the children. LPA observed the boy and girl bathrooms located outside of the classroom, to the left and down the outdoor walkway. LPA observed the outdoor play area to be spacious and provided shade for the children. LPA did not observe any hazardous items or materials in the inspected areas.

Considering this after-school-age program is located on an elementary school campus, LPA advised the Applicant to post COVID-19 related signs and to adhere to COVID-19 child care guidelines.

An exit interview was conducted with the Applicant. A copy of this form, (LIC809), was provided to the Applicant. LPA Hill requested the Applicant to read, sign, and email the the LIC809 back to LPA Hill.
SUPERVISORS NAME: Mary Ruiz
LICENSING EVALUATOR NAME: Ericka Hill
LICENSING EVALUATOR SIGNATURE: DATE: 03/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2021
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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