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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198020296
Report Date: 08/25/2021
Date Signed: 08/25/2021 02:26:43 PM

Document Has Been Signed on 08/25/2021 02:26 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:PARA LOS NINOS EARLY HEAD START: VINEFACILITY NUMBER:
198020296
ADMINISTRATOR:ANGELA CAPONEFACILITY TYPE:
830
ADDRESS:1147 VINE STTELEPHONE:
(213) 250-4800
CITY:LOS ANGELESSTATE: CAZIP CODE:
90038
CAPACITY: 18TOTAL ENROLLED CHILDREN: 0CENSUS: 13DATE:
08/25/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:41 AM
MET WITH:Carla Torres, Area SupervisorTIME COMPLETED:
02:45 PM
NARRATIVE
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At 11:41AM an unannounced in-person Case Management-Incident inspection was conducted by Licensing Program Analyst (LPA) Lissete Gonzalez to follow up on an Unusual Incident. The incident was self-reported via telephone on 08/03/2021 and via fax on 08/09/2021 to Community Care Licensing. It was reported to the Department that the incident occurred at the facility on 7/21/2021.

Upon LPA's arrival to the building at 11:41AM, LPA Gonzalez was greeted and let into the facility by Area Supervisor, Carla Torres. Also present was Early Head Start (EHS) Education in Training Coordinator, Rosalia Jimenez-Chavez. The purpose of the inspection was announced.

Area Supervisor guided LPA on a tour of the facility. Census was taken. The following staff were present during this inspection: Room 81: Staff #3, and 04 sleeping infants; Room 82: Staff #4 and Staff #5 and 3 sleeping infants; Room 83: Staff #6 and Staff #7 and 6 sleeping infants.

The Unusual Incident reported concerns of a possible violations of the Personal Rights of a infants in care in Room 81 by Staff #8 and Staff #9. Staff #8 and Staff #9 were not present during this visit.

During today's inspection, LPA obtained documentation including the children’s roster and interviews were conducted with staff. Staff disclosures corroborated the allegations that children in Room 81 were subjected to Staff #6 and Staff #7’s interference with children's sleeping and diapering needs. In addition, children sat at tables after meals for extended periods of time. Video footage of Room 81 was no longer available for review during this visit. Area Supervisor states the video footage is stored for 3 weeks only and is automatically deleted thereafter. Based upon information received from interviews conducted it was determined that the personal rights of children in care in Room 81 were violated by Staff #8 and Staff #9. This poses a potential risk to the health and safety of children in care.
REPORT CONTINUES ON NEXT PAGE: 1 OF 2
SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Lissete Gonzalez
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: PARA LOS NINOS EARLY HEAD START: VINE
FACILITY NUMBER: 198020296
VISIT DATE: 08/25/2021
NARRATIVE
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LPA obtained documentation confirming Staff #8 and Staff #9 were terminated on 8/13/2021. In addition, LPA reviewed sign-in sheets and training materials documenting that facility staff attended a Professional Development day on 8/13/2021. Topics covered included Personal Rights, Diaper Changing/Toileting, and Care & Supervision. Based on information provided, LPA cleared the deficiency cited during today’s visit.
A printed copy of this report and appeal rights (LIC 9058) was provided to Area Supervisor, Carla Torres, at the conclusion of the visit and their signature on this form acknowledges receipt of these forms.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.

END OF REPORT PAGE: 2 OF 2
SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Lissete Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/25/2021 02:26 PM - It Cannot Be Edited


Created By: Lissete Gonzalez On 08/25/2021 at 01:58 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: PARA LOS NINOS EARLY HEAD START: VINE
FACILITY NUMBER: 198020296

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/26/2021
Section Cited
CCR
101223(a)(3)

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Personal Rights - To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature including but not limited to: interference with functions of daily living including eating, sleeping or toileting; or withholding of shelter, clothing,
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Deficiency cleared during visit. LPA obtained documentation confirming Staff #8 and Staff #9 were terminated on 8/13/2021. LPA reviewed sign-in sheets and training materials documenting that facility staff attended a Professional Development day on 8/13/21. Topics covered included Personal Rights, Diaper Changing and Toileting, and Care and Supervision.
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medication or aids to physical functioning. This requirement was not met as evidenced by: During interviews, staff disclosures corroborated the allegations that the personal rights of children in Room 81 were violated by Staff #8 and Staff #9. This poses a potential risk to the health and safety of childrenin 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:Christina Gabelman
LICENSING EVALUATOR NAME:Lissete Gonzalez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2021


LIC809 (FAS) - (06/04)
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