<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198017597
Report Date: 03/07/2023
Date Signed: 03/07/2023 11:55:26 AM

Document Has Been Signed on 03/07/2023 11:55 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:PACIFIC CLINICS GLENDALE AVENUE HEAD STARTFACILITY NUMBER:
198017597
ADMINISTRATOR:EVA GUTIERREZFACILITY TYPE:
850
ADDRESS:610 N. GLENDALE AVENUETELEPHONE:
(818) 502-0628
CITY:GLENDALESTATE: CAZIP CODE:
91206
CAPACITY: 85TOTAL ENROLLED CHILDREN: 55CENSUS: 48DATE:
03/07/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Caroline Avedian, Site SupervisorTIME COMPLETED:
11:30 AM
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) Anomeh Eivazian conducted an unannounced case management inspection on 03/07/23 at 8:50 AM, due to an incident that occurred on Tuesday, 02/21/2023. LPA met with Caroline Avedian, Site Supervisor who guided analyst on a tour of the facility.

Alleged Incident took place on 02/21/2023. Incident was reported via telephone same working day. Original LIC 624 Unusual Incident/Injury Report form was received by the Department on 02/27/2023 via mail. The facility reported the incident within the required 24 hour time frame.

LPA conducted interviews with four staff. LPA obtained a copy of February and March 2023 menus, substitution menu for children with allergy for 02/21/23, child#1's medication documentation checklist, Allergy care and Epi-Pen Instruction for child#1, administration of medication form for child#1,Individual Care Plan for child#1, Medication Log for child#1.

Per staff#1, during the incident there were 14 children in the classroom with 4 staff. Per staff#1, teachers know which children have allergy or use any type of medication in their classrooms, Per staff #1, teachers complete a medication log monthly. Per staff#1, child#1 is allergic to nuts, fish and shell fish. On 02/21/23 child#1's lunch was chicken, tomatoes, onions, cilantro, lime juice, olive oil, salt and pepper. Per staff#1, catering company also have a copy of food substitution master list. Child#1 gets substitute food in different container with child'1 full name, classroom name, it identifies ( breakfast or lunch) and what the child#1 is allergic to.

Per staff#2, child#1 was on her desk, in front of her. Per staff#2, first she serves child#1's food, then served food to other children. Lunch for 02/21/23 was fish and child#1 food was chicken. Per staff#2, she had not completed serving food to all the children in her table when noticed redness around child#1's lips. Per staff#2, she informed other 3 present staff in the classroom. Child#1 was taken to library area in the
REPORT CONTINUES ON NEXT PAGE 1 OF 2
SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2023
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 2
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: PACIFIC CLINICS GLENDALE AVENUE HEAD START
FACILITY NUMBER: 198017597
VISIT DATE: 03/07/2023
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
classroom with staff#4 and staff#5 stayed with child#1. Per staff#2, staff#4 administered Epi-Pen to child#1. Per staff#2, child#1 was taken to Room 4, paramedic arrived and took the child#1 to the hospital for follow up. Per staff#2, she did not observe child #1 to touch other children food. Per staff#2, child#1 even did not start to eat lunch.

Per staff#3, during lunch time on 02/21/23 around 11:30 AM she sat on staff#2's table next to child#1, staff#2 stated child#1 had redness around lips. Per staff#3, child#1 did not start to eat lunch and did not observe child#1 to touch other children food. Per staff #3, child#1 was taken to library area in the classroom. Per staff#3, staff#4 and staff#5 went to assist child#1. Staff#4 administered Epi-Pen to child#1. Child #1 was taken to room 4, and paramedic arrived and took the child#1 to the hospital.

Per staff#4, during lunch time on 02/21/23 at 11:35 AM, staff#2 was at child#1's table and staff#4 was on the other table. Staff#2 stated she noticed redness around child#1's lips. Per staff#4, child#1 was taken to the library area in the classroom. Staff #5 was holding child#1 and comforting child#1. Per staff#4, she grabbed medication bag which was inside the classroom and reviewed child#1's medication log. Per staff#4, she observed child#1 with swollen lip, red cheeks and coughing. Per staff#4, she administered Epi-Pen to child#1 in classroom at 11:44 AM. Per staff#4, she called 911 and talked to child#1's parent. Per staff#4, child#1 was taken to Room 4, which is empty to protect other children. Per staff#4, paramedics arrived around 11:55 AM and took the child to hospital. Per staff#4, she did not observe child#1 to touch other children food as far as she was not on child#1's table.


Per Site supervisor, Caroline Avedian child#1 has Doctor appointment on 03/14/23 for follow up to see what can be the cause of child#1's allergy reaction. Per Site supervisor, child#1 was in the program since August 2022 and children were served fish, and child#1 smelled fish in the classroom but did not have any allergy reaction before. Per Site supervisor facility will take action based on child#1's doctor recommendation.
Ratio and staffing were in accordance of Title 22 Code of Regulations at the time of the incident.
LPA issued the Confidential Names List (LIC 811) to the licensee during this inspection. The Confidential Names List documents the staff and children involved with the incidents documented in this report.
At this time, the licensee is in compliance with California Title 22 Regulations. Therefore, there are no citations being issued today.
A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
Exit interview conducted and report was reviewed with the Site Supervisor, Caroline Avedian at 11:30 AM.
END OF REPORT PAGE 4 OF 4
SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Anomeh Eivazian
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2