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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198020842
Report Date: 04/02/2025
Date Signed: 04/03/2025 01:46:10 PM

Document Has Been Signed on 04/03/2025 01:46 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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:PEACE OF MIND PRESCHOOLFACILITY NUMBER:
198020842
ADMINISTRATOR/
DIRECTOR:		JOHNSON, MYAFACILITY TYPE:
840
ADDRESS:240-250 S. PARCELS ST.TELEPHONE:
(909) 629-0600
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 5TOTAL ENROLLED CHILDREN: 5CENSUS: 1DATE:
04/02/2025
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Jerry Lewis DirectorTIME VISIT/
INSPECTION COMPLETED:
06:30 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 (LPAs) Kamile Martin and Cynthia Reyes conducted an unannounced annual site Inspection to ensure the health and safety standards as required by the regulations governing child care centers are met for this school age program. LPA's met with Jarbari Tate a teacher who then notified the Director, Jerry Lewis by telephone and then who arrived shortly after and whom the visit was explained to and a copy of the Entrance Checklist for Child Care Centers form (LIC 125) was provided. The days and hours of operation are Monday to Friday from 6:30 AM – 6:00 PM. This school age program follows the Pomona unified school district holiday calendar. Licensee email address was verified/obtained during this inspection. The director was advised that the email may be public information. Upon entrance of the facility all children Infant, preschool and school age were commingled in the movie room common area. The director Jerry Lewis notified the owner Yulanda Tate who shortly arrived and Commingling was explained to the director and owner. Children were then moved into there own age group areas.

Parents enter the facility from the front entrance. Parents sign in/out is done in the front entrance. The parent board is located in the entrance lobby area as well as in each classroom and all required postings are visible for all to see. Facility has telephone service and phone number to the school was verified.

The ill/isolation area is located in the common area in front of the school age and preschool class rooms. The ill children will use the staff rest room located inside the hall located in the same common area. A mat will be used for the ill children to use and rest if needed.

LPA 's went on a guided tour with Jerry Lewis. The school age classroom is located on the left side of the building from the front entrance. LPA's took staff names, position and children census.
NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Kamile Martin
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/02/2025
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 9
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: PEACE OF MIND PRESCHOOL
FACILITY NUMBER: 198020842
VISIT DATE: 04/02/2025
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
26
27
28
29
30
31
32
Page 2

The following was observed by LPA's during this inspection.
  • School Age room #1 had one 1 Teacher and 1 Child

Teacher child ratios were discussed in accordance with Title 22 Regulations and observed. LPA's observed the licensed facility is not within the conditions, limitations, and capacity specified on the license, as children were observed commingling on this date. LPA's discussed Responsibility for Providing Care and Supervision that children should be under direct supervision and observation, including visual supervision, of a teacher at all times.

LPA's observed, age appropriate fixtures, furniture, equipment and supplies and all was inspected for age appropriateness and is in good repair. LPA's observe and inspected napping equipment (mats) & are age appropriate and in good repair if children would like to nap. Toys and play equipment were also observed to be age appropriate clean and safe. All surfaces and materials accessible to children, including toys, are toxic free. LPA's observed the facility has central heat and air, overhead lights (some were observed not working) as well natural light provided.

LPA's observed all restrooms used by children are in good condition, water temperature, paper towels, toilet paper, and all were inspected for safety, sanitation and operable. Child care centers shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well being of children, employees and visitors.
Appropriate Individual storage space was observed to be available for each child and cleanliness was observed in the classrooms. Drinking water is provided. Water and cups are available for children as needed. Facility provides breakfast, lunch and PM snack. Menus were observed posted. The school kitchen was toured for safety, cleanliness and proper equipment and supplies. A review of cleaning and food supply storage areas was made. All stored food & drinks are dated on shelves & in the refrigerator. Containers used to discard food have tight fitting lids. Licensee will take measures to keep the facility free of
NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Kamile Martin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025
LIC809 (FAS) - (06/04)
Page: 3 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: PEACE OF MIND PRESCHOOL
FACILITY NUMBER: 198020842
VISIT DATE: 04/02/2025
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
26
27
28
29
30
31
32
Page 3

Carbon monoxide detectors and smoke detectors are present and are in operable condition in each class rooms. Smoke and Carbon Monoxide detectors should be checked and batteries replaced as needed. The fire extinguisher type 2A-10BC (Service date 4/1/2024) must be serviced annually or as often as necessary

Fire and earthquake drills must be conducted every 3 months and documented. Last drills were conducted on 04/01/2025. Hazardous items including disinfectants, poisonous, cleaning solutions and any other items that could pose a danger to children were observed to be stored inaccessible to children.

Licensing staff was then guided to the outdoor play area. Children will use paper water cups LPA's observed age appropriate outdoor toys, play equipment and materials, which do need to be cleaned. the yard had debris and trash and old toys need to be removed. Adequate shade is available by use of a canopy and trees. Play yard has metal mesh gate around the play yard which is in need of replacement, it has rips and holes on the sides which causes a potential hazard to children's safety. Cushion is provided around play equipment and slides are cushioned with material to absorb a fall. LPA's advised the staff that the children need to be within the direct care and supervision, including visual observation and supervision of the teacher(s) at all times. No bodies of water were observed on the premise.

The facility has no transportation policy. Director states that any lifesaving medication will be stored in a locked area inaccessible to children in care. First aid supplies were observed to have the required items such as scissors, and twicers. There is a fully equipped first aid kit available in each class room.

Criminal Records clearance: Director was reminded that all adults 18 and over including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care center. A civil penalty of $100.00 minimum/day for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.



MyChildCarePlan.org – Licensee, was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.
NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Kamile Martin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025
LIC809 (FAS) - (06/04)
Page: 4 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: PEACE OF MIND PRESCHOOL
FACILITY NUMBER: 198020842
VISIT DATE: 04/02/2025
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
26
27
28
29
30
31
32
Page 4

Lead Testing: Assembly Bill (AB) 2370, Chapter 676, statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water used for drinking and food preparation) for lead contamination before January 1, 2023 and then every 5 years after the date of the first test. For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21,1-CCP). LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21,1-CCP. LPA referred licensee to the Department website for lead: Lead Toxicity Prevention and water Testing Information.

This facility dose not provide incidental medical services- IMS. LPA reviewed where medication and equipment and supplies are located for "0" children who have IMS and review of children's file and administrative records.
For IMS information see PIN 22-02- CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/resources/child-care-centers/.

Children’s Records were reviewed for completeness. Inspection of required forms were made and documented on the LIC 857. LPA reviewed Staff records, which are documented on the LIC 859. Staff present will be verified too have proof against TB, measles, pertussis, and influenza, as well as current Mandated reporter. LPA observed during staff file review, that there is at least one person present on this date and at all times, with Pediatric CPR & First Aid. Children's roster & Staff Personnel report was reviewed for completeness.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms.
NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Kamile Martin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025
LIC809 (FAS) - (06/04)
Page: 5 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: PEACE OF MIND PRESCHOOL
FACILITY NUMBER: 198020842
VISIT DATE: 04/02/2025
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
26
27
28
29
30
31
32
Page 5

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-carelicensing/subscribe and select the Child Care option to receive email communication.

At this time, the licensee is not in compliance with California Title 22 Regulations. Therefore, There were deficiency cited during today's Inspection in accordance to the California Code of Regulations Title 22, Division 12, Chapter 1. Consultation was given on this date.



Exit interview conducted and report was reviewed and given to Jerry Lewis, Director

Also, LPA Martin informed the licensee's to provide a copy of this licensing report dated 04/02/2025 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report.

A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.



A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Kamile Martin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025
LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 04/03/2025 01:46 PM - It Cannot Be Edited


Created By: Kamile Martin On 04/02/2025 at 04:42 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: PEACE OF MIND PRESCHOOL
FACILITY NUMBER: 198020842

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101538.3(b)
Indoor Activity Space for School-Age Children
(b) In combination programs, indoor activity space provided for school-age child care center children shall be physically separated from space provided for infant care and child care center children.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPAs observed school age, preschool, and infant children combined in one class room with one teacher.
POC Due Date: 04/03/2025
Plan of Correction
1
2
3
4
Licensee states the facility will submit a written declaration with the steps they will take to ensure that no commingling is conducted at any time. Original declaration with signature and date will be mailed and an email copy will be sent to the LPA by close of business 04/03/2025.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Christina Gabelman
NAME OF LICENSING PROGRAM MANAGER:
Kamile Martin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2025


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 04/03/2025 01:46 PM - It Cannot Be Edited


Created By: Kamile Martin On 04/02/2025 at 04:42 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: PEACE OF MIND PRESCHOOL
FACILITY NUMBER: 198020842

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record reviewthe licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.Staff #3 is missing mandated reporter certificate
POC Due Date: 04/14/2025
Plan of Correction
1
2
3
4
Per licensee Staff will complete mandated reportertraining and email a copy of LPA by POC date
Type B
Section Cited
CCR
101216(g)(2)
Personnel Requirements
(2) Each person specified in (g) above shall have a health-screening report signed by the person performing the screening. This report shall indicate the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.Staff #3 is missing the LIC 503 health Screening
POC Due Date: 04/14/2025
Plan of Correction
1
2
3
4
Per licensee A copy of the form lic 508 will be completed and emailed to LPA by POC date
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Christina Gabelman
NAME OF LICENSING PROGRAM MANAGER:
Kamile Martin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2025


LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 04/03/2025 01:46 PM - It Cannot Be Edited


Created By: Kamile Martin On 04/03/2025 at 09:04 AM
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: PEACE OF MIND PRESCHOOL
FACILITY NUMBER: 198020842

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101238.2(d)(2)
(d) The surface of the outdoor activity space shall be maintained: (2) Free of hazards including but not limited to, holes, broken glass and other debris and dry grasses that pose a fire hazard.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation the licensee did not comply with the section cited above which posed/poses a potential health and safety or personal rights risk to persons in care. Per observation the outdoor play yard needs more wood chips, the grass and trees needs to be trimmed, removal of cobwebs and broken toys and the entire yard needs a deep cleaning.
POC Due Date: 04/14/2025
Plan of Correction
1
2
3
4
Per licensee they will take photos of the entire school age play yard once all the corrctions have been made licensee will submit an e-mail to LPA with the photos of the corrections by the POC date of 04/14/2025.
Type B
Section Cited
HSC
1596.7995(a)(1)
(1) 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:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. Staff #3 is missing all immunizatons.
POC Due Date: 04/14/2025
Plan of Correction
1
2
3
4
Per licensee, they will obtain staff #3 immunizations (MMR/TDAP/FLU/TB) and will email copies to the LPA by the POC date of 04/14/2025
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Christina Gabelman
NAME OF LICENSING PROGRAM MANAGER:
Kamile Martin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2025


LIC809 (FAS) - (06/04)
Page: 9 of 9