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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198018944
Report Date: 06/10/2020
Date Signed: 06/10/2020 09:37:15 AM

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:KINDERCARE LEARNING CENTERFACILITY NUMBER:
198018944
ADMINISTRATOR:MARYAM MASSOUDIFACILITY TYPE:
830
ADDRESS:1650 STONER CREEK RD.TELEPHONE:
(626) 965-3550
CITY:CITY OF INDUSTRYSTATE: CAZIP CODE:
91748
CAPACITY:16CENSUS: 2DATE:
06/10/2020
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:06 AM
MET WITH:Maryam Massoudi TIME COMPLETED:
09:45 AM
NARRATIVE
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Licensing Program Analyst's Judy Mora and Steven Rodriguez conducted an on site Case Management inspection. Licensing staff met with Maryam Massoudi, Director who guided licensing staff on a tour of the infant classroom at approximately 8:40 AM. There were two infants present with one staff.

The purpose of this visit was to ensure that the Licensee is in compliance with Title 22 regulations. LPA Mora requested a copy of the facility roster upon arrival. During the review of the Director's form it was observed that the Child Care Facility Roster (LIC 9040) is not being used. The pertinent information on a child care roster is not on the facilities daily roster. This is a potential risk to the health and safety of children in care.

The deficiency listed on the following page was observed by licensing staff and is being cited in accordance with California Code of Regulations Title 22. Please see attached LIC 809D for deficiency that is being cited and needs to be cleared to protect the children’s health & safety.

Exit interview was conducted with Director at approximately 9:30 AM. Appeal rights explained & provided.
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Judy MoraTELEPHONE: (323) 981-3371
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2020
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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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: KINDERCARE LEARNING CENTER
FACILITY NUMBER: 198018944
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/20/2020
Section Cited

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Current roster of children provided care in facility required
Each child day care facility shall maintain a current roster of children who are provided care in the facility. The roster shall include the name, address, and daytime telephone number of the child's parent or guardian, and the name and telephone number of the
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child's physician. This roster shall be available to the licensing agency upon request.
This requirement was not met as evidenced by the Director not having a current facility roster with the pertinent information as stated above. This is a potential risk to the health and safety of chidlren 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: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Judy MoraTELEPHONE: (323) 981-3371
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2020
LIC809 (FAS) - (06/04)
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