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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198001061
Report Date: 06/02/2022
Date Signed: 09/22/2022 08:14:29 AM


Document Has Been Signed on 09/22/2022 08:14 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 09/21/2022 09:40 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

NARRATIVE
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On 06/02/22 Licensing Program Analyst (LPA) Fabiola Vasquez conducted a Case Management-Incident Inspection.

During a walk-through with the Director of the Infant component LPA Vasquez observe through the window the Piglet classroom. LPA observed 11 infants with 4 adults. 3 adults were sitting on the floor attending to the infants 1 adult was standing near the changing table moving items. LPA observed 1 infant on his back with his eyes closed with his head to the side laying on the floor carpet at arms reach to an adult who was bottle feeding another infant. LPA informed director that the infant is asleep and needs to be picked up and placed on the crib. LPA reminded the director that infants could not be asleep on the floor. Director tapped on the window the adults looked at the window, director pointed to the same infant that had his eyes closed on the floor, the adult standing up walked across the room towards that infant, the adult stopped to bend down to stop two infants from pulling each other. Then the adult picked up the sleeping infant. The infant opened his eyes began to cry, the adult soothed the infant then place the infant inside the crib.

No deficiencies were observed during the visit.

The Notice of Site Visit (LIC 9213) – 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 Director, including, but not limited to Provider Rights, Appeal Procedures

SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Fabiola VasquezTELEPHONE: (626) 361-1267
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2022
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 06/02/2022 05:57 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754


FACILITY NAME: KIDS KLUB PASADENA
FACILITY NUMBER: 198001061

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
06/03/2022
Section Cited

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If an infant falls asleep before being placed in a crib or play yard, the provider shall move the infant to a crib or play yard as soon as possible.

This requirement was not met as evidenced by:
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LPA observed 1 infant on his back with his eyes closed with his head to the side laying on the floor carpet.


This poses an immediate risk to the health 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: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Fabiola VasquezTELEPHONE: (626) 361-1267
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2022
LIC809 (FAS) - (06/04)
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