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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198017132
Report Date: 10/29/2024
Date Signed: 10/29/2024 01:18:40 PM

Document Has Been Signed on 10/29/2024 01:18 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 CENTERFACILITY NUMBER:
198017132
ADMINISTRATOR/
DIRECTOR:		IRENE SANTILLANFACILITY TYPE:
850
ADDRESS:421 S. HILLVIEW AVENUETELEPHONE:
(323) 266-4024
CITY:LOS ANGELESSTATE: CAZIP CODE:
90022
CAPACITY: 144TOTAL ENROLLED CHILDREN: 81CENSUS: 74DATE:
10/29/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Kathy Romo, Principal TIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Roxana Lopez conducted an unannounced Case Management inspection due to 1 incident that was reported to the Department on October 9th, 2024. LPA met with Principal Kathy Romo who guided LPA on a tour of the facility. Census was taken. During inspection LPA was informed of a incident that happened- where child required medical attention.

On October 8th, 2024, an incident was self reported to the Department via Email by the facility who reported child #1 had fallen hitting their head and lip, causing lip to bleed. Child required medical attention- per report incident was observed by a child # 2 and not by teachers.



On October 29th, 2024 while LPA was in the facility and incident was self reported to LPA by Principal who reported that child had sustained a head injury and was being picked up by parents to take child to the doctor. Facility also reported to the department.

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, children and obtained declarations from staff.

Regarding incident on October 8th, 2024 staff statements 1-5 corroborated that incident did occurred but was not witnessed by any staff. Per Staff 2-5 all staff were present with 10 to 13 students- 3 staff members were putting cots away and 1 was in the bathroom, no one directly supervising the classroom.-------------------------------------------------- pg. 1 of 3 ----------------------------------------------------
SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Roxana Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2024
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 4
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: 10/29/2024
NARRATIVE
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Per Staff # 2 they were putting the cots away when they noticed Child # 1 crying and trying to catch their breath, staff ran towards child as they saw child was bleeding "alot". Staff # 2 disclosed they used a sheet to apply pressure to area and child was not able to communicate what had happened. Parents were called- child was provided with first aid. Staff #2- 5 corroborated that child # 2 was crying during snack time and disclosed that they had pulled their blanket from under child # 1 causing them to fall. LPA conducted interview with child # 2 who disclosed that child # 1 was stepping on their blanket, and they pulled it causing child # 1 to hit their mouth and "bled a lot" Per child # 2 they told staff what happened.

Child # 1 was picked up from school and taken to the doctor by parents. Per Principal parents informed them the cut was in an area that cannot be stitched and it will have to heal on it's own- child was referred to a dentist. Child was out for a week but refused to stay, when they came back. Per Principal child was dis-enrolled as parents stated that child was traumatized and they didn't trust the staff.

Interviews conducted disclosed that incident which occurred October 8th, 2024 resulted in lack of supervision which is an immediate danger for the health and safety of children in care.

Regarding incident that occur on October 29th, 2024- staff statement corroborated that incident was observed. Child was not sitting properly on a bench, as they tried to get up, child fell backwards hitting their head on a nature log. Staff provided first aid immediately and notified parents. Child was taken to the doctor where they received 3 stiches- authorized representative came back the same day to inform facility, child will be back to school tomorrow.

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 of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health and safety.

-------------------------------------------------pg. 2 of 3 ----------------------------------------------------------------

SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Roxana Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: 10/29/2024
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LPA Roxana Lopez informed facility representative Kathy Romo that this report dated 10/29/2024 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 10/29/2024 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. 3 of 3 --------------------------------------------------------------------

SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Roxana Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/29/2024 01:18 PM - It Cannot Be Edited


Created By: Roxana Lopez On 10/29/2024 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: 10/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/29/2024
Section Cited
CCR
101229(a)(1)

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Responsibility for Providing Care and Supervision:The licensee shall provide care and sup.. 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 obs.. This req is not met as evidence by
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Per Prinicipal- they have already conducted meetings and trainings regardincg incident. Staff have been moved around in classrooms and they are meeting with staff relations. Per Principal they will submit a copy of agenda and signing sheet to LPA by 11/8/2024.
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Based on interviews the licensee did not comply in the section above in that 4 of 4 staff did not witness incident between child # 1 & child # 2 causing child # 1 hitting their head and lip req. medical attention.This poses an immediate risk for the health and safety of 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:Brandi VanOosten
LICENSING EVALUATOR NAME:Roxana Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2024


LIC809 (FAS) - (06/04)
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