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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198020150
Report Date: 09/21/2022
Date Signed: 09/22/2022 08:25:48 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/13/2022 and conducted by Evaluator Thelma Razo
PUBLIC
COMPLAINT CONTROL NUMBER: 33-CC-20220913132209
FACILITY NAME:MENTOR PRESCHOOL ON LAKEFACILITY NUMBER:
198020150
ADMINISTRATOR:JASMIN MANZANEROFACILITY TYPE:
850
ADDRESS:232 N. LAKE AVE #100TELEPHONE:
(626) 437-5506
CITY:PASADENASTATE: CAZIP CODE:
91101
CAPACITY:75CENSUS: 53DATE:
09/21/2022
UNANNOUNCEDTIME BEGAN:
11:38 AM
MET WITH:Jasmin Manzanero, DirectorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Uncleared adult caring and supervising children in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Thelma Razo conducted an Initial 10-Day Visit to ascertain the validity of the allegation that an uncleared adult is caring and supervising children in care. LPA arrived at 11:38AM and introduced self to Director Jasmin Manzanero. At 11:48AM, LPA toured the facility to include 3 preschool classrooms, 1 toddler classroom, toddler and preschool outdoor play area, toddler and preschool restrooms, kitchen andbreakroom.
LPA interviewed Staff #1, Staff #2, Staff #3, and Licensee (over the phone). LPA obtained pertinent documents.
Interviews have revealed that Staff #3 worked initially in the kitchen, then as a teacher assistant. According to Personnel Report (LIC500) obtained by LPA and dated today, S3 was employed on 9/10/2021 and job title is teacher assistant. Another document obtained titled Request for Employment Verification has listed S3 as an employee at this location as an assistant, dote of hire 9/10/2021. Per Licensing Facility Personnel Report Summary, S3 is not associated in this facility. Licensee has admitted that he might have overlooked and might not have fingerprinted S3.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Thelma Razo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 33-CC-20220913132209
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: MENTOR PRESCHOOL ON LAKE
FACILITY NUMBER: 198020150
VISIT DATE: 09/21/2022
NARRATIVE
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Based on LPA’s interviews, evidence gathered, and observations noted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. A deficiency was cited in accordance with Title 22, Division 12 and is on LIC9099-D.

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

A copy of this report shall also be posted where the parent/guardian of children enter and exit the facility.


Both the notice of site visit and licensing report shall remain posted for 30 consecutive days. Failure to maintain posting as required will result in a $100.00 civil penalty. A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon their return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled child for the next 12 months. A signed Acknowledgement of Receipt (LIC9224) shall be in each child’s file, acknowledging receipt.

Exit interview conducted and report was reviewed with Director Jasmin Manzanero.

SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Thelma Razo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 33-CC-20220913132209
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: MENTOR PRESCHOOL ON LAKE
FACILITY NUMBER: 198020150
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/22/2022
Section Cited
CCR
101170(e)(1)
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Criminal Record Clearance. All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility, obtain a California clearance or a criminal record exemption as required by the Department.
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Staff #3 was immediately dismissed during the inspection. Director is to submit a Declaration LIC855 to state that the facility will comply with Title 22 Section 101170(d) at all times.
A civil penalty of $100 per day with a maximum of $500. S3 worked here for more than 5 days, therefore, total amount cited
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This requirement was not met as evidenced by Staff #3 not fingerprint cleared and associated to this facility. This poses an immediate health and safety risk to the children in care.
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is S500.
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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.
SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Thelma Razo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3