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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198017113
Report Date: 11/05/2024
Date Signed: 11/05/2024 11:04:37 AM

Document Has Been Signed on 11/05/2024 11:04 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:ROSE & ALEX PILIBOS PRESCHOOLFACILITY NUMBER:
198017113
ADMINISTRATOR/
DIRECTOR:		KRISTINA MOVESSIANFACILITY TYPE:
850
ADDRESS:1611 N. KENMORE AVENUETELEPHONE:
(323) 668-0343
CITY:LOS ANGELESSTATE: CAZIP CODE:
90027
CAPACITY: 86TOTAL ENROLLED CHILDREN: 86CENSUS: 77DATE:
11/05/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:01 AM
MET WITH:Kristina Movsessian, DirectorTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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On November 05, 2024, Licensing Program Analyst (LPA) Monique Ayala conducted an unannounced Case Management inspection at the above facility. The purpose of this inspection is follow up on an incident that occurred on 08/27/2024 and was reported to the department in a timely manner on 08/27/2024. A COVID-19 risk assessment was conducted prior to entering the facility. LPA met with director, Kristina Movsessian who guided LPA on a tour of the facility. LPA observed 77 children with 14 staff members.

Brief description of incident: Child #1 (C1) was playing outdoors and tripped on C1's own foot/shoe. As a result C1 hit a wooden bench causing an injury that required stiches on right upper cheek. C1 was brought inside the classroom by Staff #1 (S1) and first aide was applied. C1's parents were called and C1 was taken to seek medical attention. C1 returned to the facility the following day.

During the inspection, LPA obtained a copy of the video surveillance footage, interviewed S1 and interviewed C1. LPA also obtained a copy of the facility roster.

There are no deficiencies being cited at this time.

An exit interview was conducted and a copy of this report was provided to director, along with appeal rights. A Notice of Site Visit was provided and must be posted for 30 days.
SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Monique Jessica Ayala
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2024
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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