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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198017663
Report Date: 12/16/2024
Date Signed: 12/16/2024 01:52:19 PM

Document Has Been Signed on 12/16/2024 01:52 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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:CRYSTAL STAIRS INC. HEAD START-MAIN STREETFACILITY NUMBER:
198017663
ADMINISTRATOR/
DIRECTOR:		HARGRAVE, KIMBERLYFACILITY TYPE:
850
ADDRESS:11819 MAIN STREETTELEPHONE:
(323) 421-2662
CITY:LOS ANGELESSTATE: CAZIP CODE:
90061
CAPACITY: 20TOTAL ENROLLED CHILDREN: 20CENSUS: 11DATE:
12/16/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Connie Jones-LoweTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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While conducting an investigation for a complaint, Licensing Program Analyst (LPA), T. Tran observed the following deficiency:

During interview conducted and record reviewed. Staff confirmed they failed to report the incident occurred on 10/22/24 to the licensing department.

Facility will complete the incident report on (LIC624 form) then submit it the licensing department.

Facility was cited a type B deficiency. See Facility Evaluation Report LIC 809D for deficiency cited.

A notice of site visit was given and must remain posted for 30 days.



Exit interview conducted and report was reviewed with the Site Lead Connie Jones-Lowe.
SUPERVISORS NAME: Denise Gibbs
LICENSING EVALUATOR NAME: Tiffanie Tran
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2024
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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Document Has Been Signed on 12/16/2024 01:52 PM - It Cannot Be Edited


Created By: Tiffanie Tran On 12/16/2024 at 12:58 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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: CRYSTAL STAIRS INC. HEAD START-MAIN STREET
FACILITY NUMBER: 198017663

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/03/2025
Section Cited
CCR
101212(1)

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Reporting requirement
This requirement is not met as evidenced by
based on interview and record reviewed facility failed to report the incident happened on 10/22/24 which poses a potential health and safety risk to children in care.
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Facility will complete LIC624 incident report in regards then submit to the licensing department for the record on or before 1/03/25 in order to clear this citation.

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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:Denise Gibbs
LICENSING EVALUATOR NAME:Tiffanie Tran
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2024


LIC809 (FAS) - (06/04)
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