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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198019814
Report Date: 07/28/2023
Date Signed: 07/28/2023 04:22:26 PM


Document Has Been Signed on 07/28/2023 04:22 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
L.A. DAY CARE-EAST, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754



FACILITY NAME:PRIMANTI MONTESSORI ACADEMYFACILITY NUMBER:
198019814
ADMINISTRATOR:HISSANKA GUNASEKARAFACILITY TYPE:
850
ADDRESS:10947 VALLEY HOME AVETELEPHONE:
(562) 943-0246
CITY:WHITTIERSTATE: CAZIP CODE:
90603
CAPACITY:124CENSUS: 82DATE:
07/28/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Academic Director, Rosalie GuzmanTIME COMPLETED:
04:45 PM
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On 7/28/23 Licensing Program Analyst (LPA) Lilli Babcock visited the facility to conduct a complaint inspection for the toddler program. During the complaint visit, a child sustained an injury while in care and paramedics were called to the facility. LPA informed Academic Director, Rosalie Guzman that LPA would be also conducting a Case Management-Incident visit regarding the injury sustained to Child #1 (C1). Personal Protective Equipment (PPE) was used by LPA. Census was taken. There were fifty-three (53) children with six (6) staff present during today's visit.

During the visit, LPA conducted interviews with, and obtained declarations from three (3) staff, and obtained supporting documentation in the form of a children’s roster (LIC 9040), photos of the injury and playground after the incident, and LIC 624 Unusual Incident/Injury Report reporting the injury to C1.

Due to insufficient information available at this time, the incident needs further investigation.

Exit interview conducted and report was reviewed with Academic Director, Rosalie Guzman.

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SUPERVISOR'S NAME: Brandi VanOostenTELEPHONE: (323) 981-3439
LICENSING EVALUATOR NAME: Lilli BabcockTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2023
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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