198017132-7-2-2024-33-CC-RLOZ-D6SRF7-20240702125841

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198017132
Report Date: 07/02/2024
Date Signed: 07/02/2024 12:58:50 PM

Document Has Been Signed on 07/02/2024 12:58 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME:	4TH STREET EARLY EDUCATION CENTER		FACILITY NUMBER:	198017132
ADMINISTRATOR/ DIRECTOR:	IRENE SANTILLAN		FACILITY TYPE:	850
ADDRESS:	421 S. HILLVIEW AVENUE		TELEPHONE:	(323) 266-4024
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90022
CAPACITY: 144	TOTAL ENROLLED CHILDREN: 100	CENSUS: 67	DATE:	07/02/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Principal, Kathy Romo		TIME VISIT/ INSPECTION COMPLETED:	01:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Roxana Lopez conducted an unannounced Case Management inspection due to 2 incidents that were reported to the Department. LPA met with Principal Kathy Romo who guided LPA on a tour of the facility. Census was taken. On April 9th 2024, an incident was self reported to the Department via Email by the facility who reported child #1 had fallen and cut their lip. On June 14th, 2024, an incident was self reported to the Department via Email by the facility who reported child# 2 had possibly fell off their chair and hurt the back of the head possibly requiring stitches. All reports were reported within the required 24 hours. The purpose of the inspection was to obtain additional information regarding the incidents reported to the Department. During the inspection, LPA Lopez conducted interviews with staff and child # 2, obtained declarations from staff and took pictures of the area. Regarding incidents that occurred on April 9th, 2024 interviews were conducted, incident was observed by staff and first aid was provided. Regarding incident that occurred on June 14th, 2024 staff statements corroborated that incident did occurred but was not witnessed by staff. Per Staff 1-3 all staff were present with 12 to 14 students. Staff # 1 was sitting at a table with children using playdough, Staff # 2 was helping children in the bathroom and Staff # 3 was in the carpet area helping two children clean the block area.---pg. 1 of 3 -

SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Roxana Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: 4TH STREET EARLY EDUCATION CENTER	FACILITY NUMBER: 198017132
	VISIT DATE: 07/02/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Child went to Staff # 2 crying holding the back of their head- Staff # 1 saw child by bathroom and initially thought that they had playdough on their hands then realized it was blood. Staff # 2 provided first aid and took child to the office. Staff corroborated that they saw child's chair located on table where there was no teacher, on the ground and assume that child was rocking on his chair and fell back, hitting their head on a shelf but did not witness actual incident. Per staff child is known for playing on their chair.

Per Child # 2 they hurt their head because they fell of the chair and their was no teacher sitting with them. Child was picked up from school and required 2 staples- Dr. note was provided and child returned to school with no restrictions.

Interviews conducted disclosed that incident which occurred June 14th, 2024 resulted in lack of supervision which is an immediate danger for the health and safety of children in care.

Based on the LPA’s observations and records reviews, the following deficiencies listed on the attached LIC 809D (deficiency page) are being cited in accordance with California Code od Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health and safety.

LPA Roxana Lopez informed facility representative Kathy Romo that this report dated 7/2/2024 document(s) 1 Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Roxana Lopez informed the facility representative to provide a copy of this licensing report dated 7/2/2024 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

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 Kathy Romo. ------------pg. 2 of 2 -----------------.

SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Roxana Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 07/02/2024 12:58 PM - It Cannot Be Edited

Created By: Roxana Lopez On 07/02/2024 at 12:22 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: 4TH STREET EARLY EDUCATION CENTER	FACILITY NUMBER: 198017132
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/02/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/02/2024 Section Cited CCR 101229(a)(1)	1 2 3 4 5 6 7	Responsibility for Providing Care and Supervision: The licensee shall provide care and supervision as necessary to meet the children's needs. No child(ren) shall be left without the supervision of a teacher at any time,Supervision shall include visual observation.	1 2 3 4 5 6 7	Per Prinicipal- they will have a meeting with staff on 7/9/2024 where they will add supervision and ratio on the agenda. Per Principal they will submit a copy of agenda and signing sheet to LPA by 7/12/2024.
	8 9 10 11 12 13 14	This req.. is not met as evidence by Based on interviews the licensee did not comply in the section above in that 3 of 3 staff did not witness child # 2 falling and hitting their head- injury that req. 2 stitches. This poses an immediate risk for the health and safety of children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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:

Brandi VanOosten

LICENSING EVALUATOR NAME:

Roxana Lopez

LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3