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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198012158
Report Date: 07/17/2024
Date Signed: 07/17/2024 03:59:14 PM

Document Has Been Signed on 07/17/2024 03:59 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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:CHILDREN'S ACADEMY OF SUCCESSFACILITY NUMBER:
198012158
ADMINISTRATOR/
DIRECTOR:		KELLY ECHEVERRIAFACILITY TYPE:
850
ADDRESS:10839 LA REINA AVENUETELEPHONE:
(562) 231-4373
CITY:DOWNEYSTATE: CAZIP CODE:
90241
CAPACITY: 48TOTAL ENROLLED CHILDREN: 24CENSUS: 20DATE:
07/17/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Bianca SigalaTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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While conducting an investigation for a complaint, Licensing Program Analyst (LPA), T. Tran observed the following deficiencies:

On June 12, 2024, facility had hired new center director and failed to report to the licensing department.

During the file reviewed, all center staff files are missing immunization records for pertussis, measles, influenza (optional), Tuberculosis (TB), and health report. S1 did not have fingerprint clearance while providing care for children at the center. Per S1, Livescan was completed on 7/12/24 and pending on the result. S1 was immediately removed from the facility until the fingerprint process is cleared and associated to the facility upon return.

Facility representative was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Childcare Center. A civil penalty of $500.00 have been assessed.

Facility was cited a type A and B deficiencies. See Facility Evaluation Report LIC 809D for deficiencies cited.
Upon receipt of a Type A deficiency, facility shall post and provide copies of this licensing report to parent/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.

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 conducted and report was reviewed with the facility representative, Bianca Sigala.

SUPERVISORS NAME: Denise Gibbs
LICENSING EVALUATOR NAME: Tiffanie Tran
LICENSING EVALUATOR SIGNATURE: DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2024
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 07/17/2024 03:59 PM - It Cannot Be Edited


Created By: Tiffanie Tran On 07/17/2024 at 02:35 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: CHILDREN'S ACADEMY OF SUCCESS
FACILITY NUMBER: 198012158

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/17/2024
Section Cited
CCR
101216(i)(1)

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This requirement is not met as evidenced by based on record review and observation facility failed to obtain fingerprint clearances for S1 and must be associated to facility. which poses an immediate health and safety risk to children in care.
Civil penalty have been assessed.
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During today's visit, Center director immediately removed S1 from the facility.
Livescan form must provided to the department or S1 must have fingerprint clearance upon report back to work at this facility in order to clear this citation.

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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:Denise Gibbs
LICENSING EVALUATOR NAME:Tiffanie Tran
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2024


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Document Has Been Signed on 07/17/2024 03:59 PM - It Cannot Be Edited


Created By: Tiffanie Tran On 07/17/2024 at 03:09 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: CHILDREN'S ACADEMY OF SUCCESS
FACILITY NUMBER: 198012158

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/17/2024
Section Cited
CCR
101212(b)

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Personnel Requirements
This requirement is not met as evidenced by based on record review and interview facility failed to report new hired director on June 12. 2024 which poses a potential health and safety risk to children in care.
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Center director states she will comply with the regulations and will notify the owner to report her new role and all required documents to the licensing department for review by or before 7/17/24 in order to clear this citation.


Type B
08/16/2024
Section Cited
HSC
1596.7995

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Employees or volunteers at day care center; immunization requirements.
This requirement is not met as evidenced by based on record review facility failed to have staff #2, #3 & #4 immunization records for Pertussis, Measles, Influenza, health report, and TB which poses a potential health and safety risk to children in care.
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Center director agrees to have all staff complete the required immunization, health report, and TB then submit the licensing department for review by or before 08/16/24 in order to clear this citation

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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:Denise Gibbs
LICENSING EVALUATOR NAME:Tiffanie Tran
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2024


LIC809 (FAS) - (06/04)
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