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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198015475
Report Date: 12/01/2022
Date Signed: 12/01/2022 01:01:20 PM

Document Has Been Signed on 12/01/2022 01:01 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:JOHN W. MACK CENTER, USC HEAD STARTFACILITY NUMBER:
198015475
ADMINISTRATOR:DEBBIE GIPSONFACILITY TYPE:
850
ADDRESS:3020 SOUTH CATALINA STREETTELEPHONE:
(213) 743-4651
CITY:LOS ANGELESSTATE: CAZIP CODE:
90007
CAPACITY: 45TOTAL ENROLLED CHILDREN: 30CENSUS: 20DATE:
12/01/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Joanna WilliamsTIME COMPLETED:
01:20 PM
NARRATIVE
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While conducting a case management incident on 12/1/2022, Licensing Program Analyst (LPA), T.Tran observed the following deficiency:

Based on staff record reviewed, S6 is not a qualified teacher assistant working in room 106 with children due to no records of completion or enrolling in early childhood education or child development units. Per facility representative, S6 was working with two fully qualified staff for the maximum of 15 children and was never left alone supervising the children. LPA observed there is no immediately risk to children in care because record indicated S6 has fingerprint cleared and associated to the above facility. S6 was immediately removed from the center during today's visit. LPA obtained a declaration statement indicate S6 will longer working here or any other sites and will be dissociated to the agency as of 12/1/2022.


Facility was cited a type B deficiency. See Facility Evaluation Report LIC 809D for deficiency cited.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the facility representative Joanna Williams.

SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Tiffanie Tran
LICENSING EVALUATOR SIGNATURE: DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2022
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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Document Has Been Signed on 12/01/2022 01:01 PM - It Cannot Be Edited


Created By: Tiffanie Tran On 12/01/2022 at 12:29 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: JOHN W. MACK CENTER, USC HEAD START
FACILITY NUMBER: 198015475

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/01/2022
Section Cited
CCR
101216.2(a)(d)

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Teacher aide Qualification
This requirement is not met as evidenced by based on record review facility failed to provide S6 records of completion or enrolling in early childhood education or child development units. S6 is fingerprint cleared and associated to the facility
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Facility representative immediately removed S6 from the center during today's visit. LPA obtained a declaration statement indicate S6 will longer be working here or any other sites and will be dissociated to the agency as of 12/1/2022. POC cleared during today's visit.
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which poses a potential health and safety risk to 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:Trevino Cochran
LICENSING EVALUATOR NAME:Tiffanie Tran
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2022


LIC809 (FAS) - (06/04)
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