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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198019999
Report Date: 10/28/2021
Date Signed: 10/28/2021 02:58:31 PM

Document Has Been Signed on 10/28/2021 02:58 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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:NLMUSD PRESCHOOL PROGRAM-MOFFITT ELEMENTARYFACILITY NUMBER:
198019999
ADMINISTRATOR:PAMELA BURNSFACILITY TYPE:
850
ADDRESS:13323 S GOLLER AVETELEPHONE:
(562) 210-4205
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 40TOTAL ENROLLED CHILDREN: 40CENSUS: DATE:
10/28/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Pamela Burns, Teacher/Site SupervisorTIME COMPLETED:
03:15 PM
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), T. Tran arrived at the above licensed facility to conduct a Case Management Incident inspection that was self-reported on 10/18/2021 regarding a child in care was left unattended in the children's restroom for approximately 20 seconds. The Monterey Park South West Child Care Regional Office received the incident report on 10/25/2021. About 12:50 LPA toured the classrooms and observed proper care and supervision.

LPA completed children and staff files review. LPA obtained personnel report and child's document. Interviews was conducted with staff, child, and other. Per staff, on the day of the incident there were 17 children with 2 staff. Based on the observation, the children's restroom is connected between RM1 and RM2. Staff indicated, child was left alone in the restroom for no longer then 5 seconds. However, the children's restroom was within the classrooms perimeter. Child observed to have no signs of discomfort. Parent was informed. Based on the available information it does not appear this incident was the result of a Title 22 violation for lack of care and supervision.

No deficiency was issued during today's visit. 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 Pamela Burns.

SUPERVISORS NAME: Trevino Cochran
LICENSING EVALUATOR NAME: Tiffanie Tran
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2021
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 1