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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198010030
Report Date: 11/18/2022
Date Signed: 11/18/2022 01:59:13 PM

Document Has Been Signed on 11/18/2022 01:59 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:WAVERLY SCHOOL, THEFACILITY NUMBER:
198010030
ADMINISTRATOR:JOHN CERVANTESFACILITY TYPE:
850
ADDRESS:67 W. BELLEVUETELEPHONE:
(626) 792-5940
CITY:PASADENASTATE: CAZIP CODE:
91105
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 20DATE:
11/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Molly Geller, Elementary DirectorTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Bardo Baluyot conducted an unannounced Required Annual site Inspection. LPA met with Elementary Director, Molly Geller who guided LPA on a tour of the facility. Licensee also has a K-12 private school which operates on the same grounds. There are no shared areas between the preschool and private school.

LPA observed 20 children with 4 staff present. LPA inspected all areas identified on the Facility Sketch.
Students have access to the classroom, restrooms (located in the classroom) and outdoor play area which is fenced and kept separated from elementary school play area. Students of the program are signed in at the main entrance or the playground and escorted to their assigned classrooms by their teachers. The facility does not provide transportation. Furniture and equipment were observed to be safe and in good repair. There is telephone service, heating, lighting and ventilation available at the facility. The main office as well as staff offices are used as an isolation area if needed. Per Director, ill children use the classroom restroom.

Drinking water is available indoors and outdoors via personal water bottles and are refilled by staff upon request. Restrooms used were inspected for availability, good repair, area safety and sanitation.

Per Director, children bring their own lunches but the facility offers an option for children to buy lunch from Fresh Lunch a program that brings food to the facility. The facility does provide A.M. and P.M. snack for the children which are primarily dry/packaged snacks. LPA's observed snack menus posted and current.
SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Bardo Baluyot
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2022
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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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: WAVERLY SCHOOL, THE
FACILITY NUMBER: 198010030
VISIT DATE: 11/18/2022
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Outdoor playground equipment is in safe condition, free of sharp, loose or pointed parts. The play area has shade sails to provide shade. The surface of the outdoor activity space is maintained in a safe condition and is free of hazards. The play area has a sand box for children to play in as well as other toys. The play area is fully fenced. First Aid supplies are available. Disaster drills are documented and all posting requirements have been met. Last drills were recorded as being conducted on 10/20/22.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

No deficiencies were cited in accordance with California Code of Regulations Title 22.

Exit interview conducted and report was reviewed with the Elementary Director, Molly Gellar and Pre-school Director, Consuelo Rodarte.


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.

LPA advised how to access forms, regulations and quarterly updates on line at: www.ccld.ca.gov.



To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process
SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Bardo Baluyot
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022
LIC809 (FAS) - (06/04)
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