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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198020492
Report Date: 10/13/2021
Date Signed: 10/13/2021 03:46:05 PM

Document Has Been Signed on 10/13/2021 03:46 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:ROOSEVELT INFANT CENTERFACILITY NUMBER:
198020492
ADMINISTRATOR:ANN CHO-LIMFACILITY TYPE:
830
ADDRESS:456 S. MATTHEWSTELEPHONE:
(323) 780-6636
CITY:LOS ANGELESSTATE: CAZIP CODE:
90033
CAPACITY: 24TOTAL ENROLLED CHILDREN: 8CENSUS: 6DATE:
10/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:32 AM
MET WITH:Veronica Ibarra, Lead TeacherTIME COMPLETED:
03:50 PM
NARRATIVE
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At 11:32AM, Licensing Program Analysts (LPAs) Mireya Garcia and Steven Tung conducted an unannounced required inspection. A risk assessment was conducted prior to entering the facility. Due to COVID- 19 precautionary measures were taken, licensing staff present during inspection wore appropriate personal protective equipment. LPAs met with Lead Teacher, Veronica Ibarra, who guided LPAs on a tour of the facility. Principal Ann Cho-Lim later arrived at 12:15PM and departed at 12:51PM. This is an infant program licensed for 24 children. This facility operates Monday – Friday from 7:30AM – 3:30PM. Per the Lead Teacher there are 8 children enrolled. This is an infant center with toddler option located on the same premises as Roosevelt High School.

At approximately 11:37AM, LPA M. Garcia and LPA S. Tung began facility tour with Lead Teacher. All areas identified on the facility sketch were inspected. LPAs observed 3 toddlers with Staff #1 and Staff #2 in the Toddler Room and 3 infants with Staff #3 and Staff #4 in the infant room. Teacher-infant ratios were observed to be in accordance with Title 22 regulations. The Licensee is within the conditions, limitations, and capacity specified on the license. Staff names were recorded. All children were observed to be under visual supervision of a teacher at all times. Classrooms were observed to ensure that infants are never left unattended and under the direct visual supervision of a staff person at all times.

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SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Steven Tung
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2021
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: ROOSEVELT INFANT CENTER
FACILITY NUMBER: 198020492
VISIT DATE: 10/13/2021
NARRATIVE
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The facility was inspected to ensure that it is clean, safe, sanitary, and in good repair to ensure the safety and well being of children, employees and staff. Furniture and equipment was inspected for good repair, free of sharp, loose, or pointed parts. The facility has age appropriate furniture and equipment including but not limited to cribs, cots/mats and changing tables. LPAs observed that infant changing tables are within an arm’s reach of a sink. LPAs observed sufficient infant napping equipment that meets the requirements of Title 22 regulations. LPAs did not observe any baby walkers or any items that fall into that category present in the facility. There are currently no children enrolled who require medication. The office is used as an isolation area and is furnished with chairs. Parents are contacted immediately when children are determined to be ill.

The facility provides meals for the toddlers and each parent provides milk for their infant. LPAs observed that bottles, dishes, and containers of food brought by the infant’s authorized representatives are labeled with the infant’s name and current date. All storage containers for solid waste, including moveable bins, have tight fitting covers on and are in good repair. Disinfectants, cleaning solutions, poisons and other items that are dangerous to children are stored in an area inaccessible to toddlers and infants. Per Lead Teacher, states that there are no poisons stored at the facility. LPAs advised Lead Teacher that storage areas for poisons need to be kept locked. Facility has one or more functioning carbon monoxide detectors that meet statutory requirements. The Lead Teacher, takes measures to keep the facility free of flies, other insects and rodents.

Outdoor play equipment was observed to be in good condition, free of sharp, loose or pointed parts. Outdoor activity space surface is maintained in a safe condition and is free of hazards. LPAs did not observe any bodies of water on the facility premises.

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SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Steven Tung
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021
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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: ROOSEVELT INFANT CENTER
FACILITY NUMBER: 198020492
VISIT DATE: 10/13/2021
NARRATIVE
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Sign in and out sheets were reviewed to ensure that children present are signed in. Staff Records were reviewed to ensure that personnel records are maintained on all staff. Staff #1's file was missing the immunization record. Teachers present have required infant units on file and are qualified. Children’s Records were reviewed to ensure that each child has a separate, complete, and current record, a Needs and Services Plan, and a medical assessment are on file. LPAs observed the LIC 9227 Individual Infant Sleeping Plan in files. LPAs issued the Children’s Record Review (LIC 857) and the Review of Staff records (LIC 859) to the Lead Teacher during this inspection. Criminal Records Clearance for adults and verification of CPR/First Aid and health preventative practices documentation was reviewed.

SB792 Immunization Requirements for Staff and Employees was discussed with the Lead Teacher.

AB1207 Mandated Child Abuse Reporting – Implementation was discussed with Lead Teacher. Website provided: http://mandatedreporterca.com/

This facility provides Incidental Medical Services – IMS. LPAs reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. Per Lead Teacher, there are currently no children enrolled who have medication needs. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226.The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

LPAs provided the following documents about Safe sleep: PIN 19-02-CCP Safe Sleep Awareness Campaign and PIN 20-24-CCP Recently Approved Safe Sleep Regulations in Effect.


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SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Steven Tung
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021
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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: ROOSEVELT INFANT CENTER
FACILITY NUMBER: 198020492
VISIT DATE: 10/13/2021
NARRATIVE
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LPAs advised the Lead Teacher to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov.

The following deficiency listed on the attached LIC 809D is being cited in accordance with California Code of Regulations Title 22.

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.



Exit interview was conducted with Lead Teacher, Veronica Ibarra. Appeal Rights and Procedures explained and provided.

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SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Steven Tung
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/13/2021 03:46 PM - It Cannot Be Edited


Created By: Steven Tung On 10/13/2021 at 03:00 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: ROOSEVELT INFANT CENTER
FACILITY NUMBER: 198020492

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/27/2021
Section Cited
HSC
1596.7995(a)(1)

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Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.This requirement is not met as evidenced by:
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Per Lead Teacher, Veronica Ibarra, copies of the immunization records for Staff #1 will be submitted via email to LPA Garcia by POC due date of 10/27/2021.
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LPAs observed that Staff #1 did not have immunization records. This poses a potential health and safety risk to children 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:Brandi VanOosten
LICENSING EVALUATOR NAME:Steven Tung
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2021


LIC809 (FAS) - (06/04)
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