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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197495082
Report Date: 04/06/2023
Date Signed: 04/06/2023 11:44:45 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/25/2023 and conducted by Evaluator Miriam Cohen
COMPLAINT CONTROL NUMBER: 30-CC-20230125145744
FACILITY NAME:EXCELSIOR PRESCHOOL TORRANCE LLCFACILITY NUMBER:
197495082
ADMINISTRATOR:KIARA ORTIZFACILITY TYPE:
850
ADDRESS:19801 MARINER AVENUETELEPHONE:
(424) 375-6188
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY:72CENSUS: 4DATE:
04/06/2023
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Kiara Ortiz, DirectorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Unqualified staff providing care and supervision to children
INVESTIGATION FINDINGS:
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On 04/06/2022 @ 9:40 AM, Licensing Program Analyst (LPA) Miriam Cohen conducted an unannounced complaint visit for the purpose of delivering the findings against alleged complaint reported concerning the above preschool. Upon arrival, LPA Cohen observed two adults providing care for four children. LPA Cohen met with preschool director, Kiara Ortiz.
LPA Cohen substantiated the allegation – Unqualified staff providing care and supervision to children based on interviews, incident report, and declarative statement from staff members. The facility was cited a Type A deficiency according to California Code of Regulations Title 22 (See LIC 9099D report for deficiencies). Licensee is to post notice of Site Visit for 30 Days, failure to do so will result in $100 immediate civil penalty. This report must be copied and given to all parents and to the parents of any child enrolling within the next 12 months. An exit interview, a copy of the report, and Appeal Rights were provided to the preschool director.
SUBSTANTIATED - A finding that a complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maureen NealTELEPHONE: (424) 301-3042
LICENSING EVALUATOR NAME: Miriam CohenTELEPHONE: (424) 301-3058
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 30-CC-20230125145744
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: EXCELSIOR PRESCHOOL TORRANCE LLC
FACILITY NUMBER: 197495082
VISIT DATE: 04/06/2023
NARRATIVE
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On 04/06/2022 @ 9:40 AM, Licensing Program Analyst (LPA) Miriam Cohen conducted an unannounced complaint visit for the purpose of delivering the findings against alleged complaint reported concerning the above preschool. Upon arrival, LPA Cohen observed two adults providing care for four children. LPA Cohen met with preschool director, Kiara Ortiz.
LPA Cohen substantiated the allegation - Staff did not report incident to appropriate parties based on the interview with preschool director. Per director, LIC 624 form (Unusual Incident Report or UIR) was not submitted to Community Care Licensing (CCL) after an incident occurred where C1 fell on the ground and bump head on hard wood floor after hugging another child.
The facility was cited a Type “B” violation. An exit interview and a copy of the report and Appeal Rights were provided to the preschool director.
SUBSTANTIATED - A finding that a complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

On 02/01/2023 @ 9:30 AM, Licensing Program Analyst (LPA) Miriam Cohen conducted an unannounced complaint visit for the purpose of notifying the preschool director concerning the above-mentioned allegations and to perform an investigation. Upon arrival, LPA Cohen observed two adults providing care for four children. LPA Cohen met with preschool director, Kiara Ortiz.
LPA acquired the following documentation:
*Children Roster
*Emergency ID of parent contact information
*LIC 624 forms (UIR) for 12/28/2022 & 01/12/2023
*LIC 308 form (Designation of Responsibility) 02/01/2023
*Written declaration from three members
LPA interviewed and obtained written declaratives from three members including preschool director; however, further witnesses and documentation will be needed to conclude the investigation. An exit interview was conducted with the above items discussed with preschool director. A copy of this report was provided.
SUPERVISOR'S NAME: Maureen NealTELEPHONE: (424) 301-3042
LICENSING EVALUATOR NAME: Miriam CohenTELEPHONE: (424) 301-3058
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 30-CC-20230125145744
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: EXCELSIOR PRESCHOOL TORRANCE LLC
FACILITY NUMBER: 197495082
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/07/2023
Section Cited
CCR
101216.1(c)(1)
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Teacher Qualifications and Duties
To be a fully qualified teacher, a teacher shall have one of the following: Twelve postsecondary semester...
This requirement is not met as evidenced by observation and records review conducted during an unannounced visit on 02/01/2023. The director failed to ensure that transcripts
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Director agrees to provide a written statement, using LIC 855 (Declaration Form) on intention to keep children safe at all times including obtaining proof of transcripts with required ECE or CD units and filing documentation prior to staff members commencement of work. Declaration to be submitted to LPA by

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with required ECE or CD units have been obtained and on file prior to commencement of work. This poses an immediate risk to the health and safety risk of children in care. LPA did not observe proof of transcript for staff #1.

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04/07/2023, end of business day.
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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: Miriam CohenTELEPHONE: (424) 301-3058
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 30-CC-20230125145744
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: EXCELSIOR PRESCHOOL TORRANCE LLC
FACILITY NUMBER: 197495082
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/14/2023
Section Cited
CCR
101212(d)(1)(B)
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Reporting Requirements
Upon the occurrence...
This requirement is not met as evidenced by interview with preschool director and records review conducted during an unannounced visit on 02/01/2023. The director failed to submit LIC 624 form (Unusual Incident Report) to the

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*The director agrees to provide a written statement using LIC 855 (Declaration Form) on intention to report all unusual incidents to the department in a timely manner per Title 22 Regulations.
*The director agrees to view a CCL video on Child Care Reporting Requirements:


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department on a timely manner. This poses a potential risk to the health and safety of children in care. The director did not report the Unusual Incident to the department on the next working day after the incident. The director did not submit a written report (LIC 624 form) to the department within seven days following the occurrence of the incident.
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https://ccld.childcarevideos.org/child-care-center-operators/child-care-reporting-requirements/
*The director agrees to provide a written statement of completion and short narrative regarding the video, using LIC 855 (Declaration Form). Declaration to be sent to LPA, via email, by 04/14/2023, end of business day.
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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: Miriam CohenTELEPHONE: (424) 301-3058
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4