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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198007425
Report Date: 02/27/2023
Date Signed: 02/27/2023 11:23:22 AM

Document Has Been Signed on 02/27/2023 11:23 AM - 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:CERRITOS CHILD DEV. CENTERFACILITY NUMBER:
198007425
ADMINISTRATOR:VANESSA GUZMANFACILITY TYPE:
850
ADDRESS:120 E. CERRITOS AVE.TELEPHONE:
(818) 243-3212
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY: 85TOTAL ENROLLED CHILDREN: 83CENSUS: 59DATE:
02/27/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Perla Leyvas, Program SupervisorTIME COMPLETED:
11:40 AM
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Licensing Program Analysts (LPA) Anomeh Eivazian and Mary Silva conducted an unannounced case management inspection on 02/27/23 at 10:30 AM, due to an incident that occurred on Friday, 02/10/23. LPAs met with Perla Leyvas, Program Supervisor who guided analyst on a tour of the facility.

Alleged Incident took place on 02/10/2023, however mother of child#1 reported the injury to school on Tuesday 02/14/2023. Incident was reported via email same working day. Original LIC 624 Unusual Incident/Injury Report form was received by the Department within 7 days. The written incident report was received by email on 02/14/2023. The facility reported the incident within the required 24 hour time frame.

LPAs observed the area where alleged incident took place on 02/27/2023 at 10:40 AM. LPAs conducted interviews with staff#1 and staff#2.

Per staff # 1 and staff#2, on 02/10/2023 at 4:10 p.m., child #1 was playing with other children on the preschool playground. Child#1 came down the blue 3 foot preschool slide, got up and ran over to the adjoining red preschool slide. Per staff#1, she observed child#1 bump head on the red slide and fell back on her bottom. At the time of the incident, child#1 did not complaint of leg pain while was in the school. Staff applied ice, comforted child#1 and child#1 was picked up at 4:30 p.m..

Per Peral Leyvas, Program Supervisor, parent#1 reported school on 02/14/2023 that child#1 was hurting when they got home and on 02/11/2023 child#1 was taken to Emergency Room and was discovered child#1 had a leg fracture.
REPORT CONTINUES ON NEXT PAGE 1 OF 2
SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE: DATE: 02/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2023
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
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: CERRITOS CHILD DEV. CENTER
FACILITY NUMBER: 198007425
VISIT DATE: 02/27/2023
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LPAs assess the playground where the alleged incident occurred and did not observe any hazards. Pictures were taken from outdoor playarea. LPAs obtained a copy of child#1 Urgent Care report dated 02/13/2023.

Per Peral Leyvas, Program Supervisor at the time of the incident total of 35 preschoolers were on the playground with 5 staff.



LPA issued the Confidential Names List (LIC 811) to the licensee during this inspection. The Confidential Names List documents the staff and children involved with the incidents documented in this report.

There are no citations being issued today.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the Perla Leyvas, at 11:40 AM.


END OF REPORT PAGE 2 OF 2
SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023
LIC809 (FAS) - (06/04)
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