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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198016407
Report Date: 10/12/2023
Date Signed: 10/12/2023 10:30:32 AM

Document Has Been Signed on 10/12/2023 10:30 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:CII/OTIS BOOTH CDCFACILITY NUMBER:
198016407
ADMINISTRATOR:PRISCILLA ALMEJOFACILITY TYPE:
850
ADDRESS:424 N. LAKE STREETTELEPHONE:
(213) 260-7717
CITY:LOS ANGELESSTATE: CAZIP CODE:
90028
CAPACITY: 40TOTAL ENROLLED CHILDREN: 40CENSUS: DATE:
10/12/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Priscilla Almejo, Site SupervisrTIME COMPLETED:
10:45 AM
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On October 12, 2023, Licensing Program Analyst (LPA) Monique Ayala conducted an unannounced case management inspection for an incident that occurred on 09/11/2023. The incident was reported to the department in a timely manner on 09/12/2023. A COVID-19 risk assessment was assessed prior to entering the facility. LPA met with Site Supervisor, Priscilla Almejo who guided LPA on a tour of the facility. LPA observed 14 children in care.

Brief Summary: On 09/11/2023, Substitute teacher/staff #1 (S1) was working in toddler 1 class and observed Child #1 (C1) with a chapped lip. Later C1's lip looked red which caused S1 to look closer at C1's lip. S1 realized C1 has a cut on his inner lip. Per Site Supervisor, C1 did not fall or hit himself at the facility; the incident may have happened at C1's home.

During the inspection LPA interviewed Parent #1 (P1), Staff #2 (S2), Site Supervisor, obtained a copy of incident report and facility roster. LPA attempted to interview Child #1 (C1); C1 did not qualify to be interviewed. LPA obtained contact information for S1.

There are no deficiencies being given at this time as the incident required further investigation.

An exit interview was conducted and a copy of this report was provided to Site Supervisor along with Notice of Site Visit. Notice of Site Visit must be posted for 30 days.
SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Monique Jessica Ayala
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2023
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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