<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198004738
Report Date: 05/09/2023
Date Signed: 05/09/2023 03:32:17 PM

Document Has Been Signed on 05/09/2023 03:32 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:PUEBLO CHILD DEVELOPMENT CENTERFACILITY NUMBER:
198004738
ADMINISTRATOR:KYM ALLENFACILITY TYPE:
850
ADDRESS:1444 E. HOLT AVE., ROOM 3TELEPHONE:
(909) 994-3796
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 32TOTAL ENROLLED CHILDREN: 5CENSUS: 4DATE:
05/09/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Kym Allen TIME COMPLETED:
02:05 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) conducted a case management inspection due to an incident that occurred on 04/23/2015. LPA met with Kym Allen, Child Development Facilities Licensing Planner. LPA observed 04 napping children with 02 staff at the time of inspection. LPA conducted interviews during this visit. This is a subsequent inspection to the initial inspection conducted on 04/27/23.

The incident that occurred on Wednesday, March 8, 2023 was reported to the Department via telephone and email within the required 24 hours.

Based on the information obtained during this investigation, it was found that staff #1 grabbed child #1 by the face because the child was going to bite another child. Staff #1 violated child #1's personal rights. There were witnesses who observed this incident. This was an immediate risk to the health and safety of the child in care.

Upon receipt of this report, the licensee shall post ANY licensing report documenting a type “A” citation. This must remain posted for 30 days during hours of operation. In addition to posting this report, the licensee will also provide copies to the parents of the children in care for up to one year.

A copy of the LIC 9224 - Acknowledgement of Receipt of Licensing Reports was provided.

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. The deficiency listed on the following page was observed by the LPA and is being cited in accordance with California Code of Regulations Title 22. Please see attached LIC 809d. Deficiency that is being cited needs to be cleared to protect the children’s health & safety.

Exit interview was conducted with Kym Allen. Appeal rights explained & provided.
SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Judy Mora
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 05/09/2023 03:32 PM - It Cannot Be Edited


Created By: Judy Mora On 05/09/2023 at 01:56 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: PUEBLO CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 198004738

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/10/2023
Section Cited
CCR
101223(a)(3)

1
2
3
4
5
6
7
Personal Rights
The licensee shall ensure that each child is accorded the following personal rights (3)To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a
1
2
3
4
5
6
7
Kym Allen states that Assistant DIrector of Education will submit a Plan of Correction to LPA on 05/11/23.
8
9
10
11
12
13
14
 interference with functions of daily living including eating, sleeping or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.
This requirement was not met as evidenced by disclosures made during
punitive nature including but not limited to:
interviews. On 03/08/23, S1 grabbed C1’s face and shook it due to the child biting. This was a violation of the child’s personal rights. This is an immediate risk to the health and safety of children in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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 Guangorena
LICENSING EVALUATOR NAME:Judy Mora
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2