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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198011002
Report Date: 11/04/2021
Date Signed: 11/04/2021 02:15:25 PM

Document Has Been Signed on 11/04/2021 02:15 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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:LOS ANGELES ADVENTIST ACADEMYFACILITY NUMBER:
198011002
ADMINISTRATOR:JACQUELINE GALBREATHFACILITY TYPE:
850
ADDRESS:846 E.EL SEGUNDO BOULEVARDTELEPHONE:
(323) 743-8818
CITY:LOS ANGELESSTATE: CAZIP CODE:
90059
CAPACITY: 40TOTAL ENROLLED CHILDREN: 15CENSUS: 14DATE:
11/04/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:59 AM
MET WITH:Cassandra Hudson-Johnson, Acting DirectorTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Alicia Mooberry conducted a case management inspection. LPA met with Cassandra Johnson, Director. LPA inspected the facility inside and outdoors.
This facility is located on the grounds of LA Adventist Academy, a private school age facility. The preschool facility is enclosed and gated. Room 2 "The Little Lambs" (age 4-5 years) there were 11 children and 1 staff. There as 1 staff and 3 children in Room 1 (ages 2-3 years). LPA reminded the director to ensure the preschool program stays separate from the Private school children.
During this inspection LPA consulted with the Acting Director about the New Director documentation since the previous director is no longer at the facility.

During tour of facility LPA observed the following deficiencies:
During the facility file review the director did not have a facility roster available This poses a potential risk to the health and safety of children in care.

Deficiencies cited are on attached LIC 809D.
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.

Exit interview was conducted with Cassandra Hudson-Johnson, Director.

SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Alicia Mooberry
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2021
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 11/04/2021 02:15 PM - It Cannot Be Edited


Created By: Alicia Mooberry On 11/04/2021 at 01:08 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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: LOS ANGELES ADVENTIST ACADEMY
FACILITY NUMBER: 198011002

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/08/2021
Section Cited
HSC
1596.841

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1596.841 Current roster of children provided care in facility required: Each child day care facility shall maintain a current roster of children who are provided care in the facility...This roster shall be available to the licensing agency upon request.
This requirement os not met as evidenced by:
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The Director will complete a faciltiy roster and will send it via email to the department by POC due date.
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Based on record review the Facilty Children's roster was not completed and available for review. This poses a potential 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:Valarie Cook
LICENSING EVALUATOR NAME:Alicia Mooberry
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2021


LIC809 (FAS) - (06/04)
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