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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197495117
Report Date: 03/21/2024
Date Signed: 03/21/2024 02:50:01 PM

Document Has Been Signed on 03/21/2024 02:50 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:ABC PRE SCHOOL HOUSEFACILITY NUMBER:
197495117
ADMINISTRATOR:NINELIE RATAVOSSIANFACILITY TYPE:
850
ADDRESS:4102-4104 W VICTORY BLVDTELEPHONE:
(818) 934-0049
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY: 53TOTAL ENROLLED CHILDREN: 53CENSUS: 41DATE:
03/21/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Licensee Representative / Bhagya FernandoTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced Case Management Visit to this facility. Upon arrival, LPA met with Licensee Representative / Bhagya Fernando, who guided LPA on a tour of the facility. There were 41 children with 5 staff observed at the time of visit.

LPA Katrdzhyan discovered that the facility failed to report an incident which took place on 1/11/24, where Child 1 (C1) sustained a bite mark from Child 2 (C2), on the face/right cheek. Per Licensee Representative / Bhagya Fernando, it was disclosed that the facility failed to report the incident to CCL, per Title 22 Reporting Requirements, Section 101212.

Licensee Representative / Bhagya Fernando understands the importance of reporting requirements and will submit an Unusual Incident/Injury Report to CCL by no later than the end of business day on 3/22/214, regarding the incident involving C1 and C2.

An Advisory Note - Technical Violation was issued during today's visit stating that Title 22 Regulations Section 101212 was discussed with Licensee Representative / Bhagya Fernando and an In-service Training will be conducted and copies of the training along with signatures of all attendees will be submitted to CCL by the end of business day on 4/4/24.

The Notice of Site Visit was provided and must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.

Exit interview was conducted with Bhagya Fernando and Appeals Rights provided.
SUPERVISORS NAME: Rita Ramos
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2024
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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