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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198020953
Report Date: 09/27/2024
Date Signed: 09/27/2024 02:18:29 PM

Document Has Been Signed on 09/27/2024 02:18 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:BRELLA HOLLYWOODFACILITY NUMBER:
198020953
ADMINISTRATOR/
DIRECTOR:		REBECCA KELLYFACILITY TYPE:
850
ADDRESS:909 N. ORANGE DR.TELEPHONE:
(213) 300-5962
CITY:LOS ANGELESSTATE: CAZIP CODE:
90038
CAPACITY: 45TOTAL ENROLLED CHILDREN: 50CENSUS: 19DATE:
09/27/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Director, Rebecca KellyTIME VISIT/
INSPECTION COMPLETED:
02:25 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) Staicy Perry conducted an unannounced Case Management inspection. Upon arrival LPA met with Director Rebecca Kelly. Director guided LPA on a tour of the facility. The purpose of the inspection is to follow up on an Unusual Incident reported to the regional office. Census was taken. LPA observed 19 children and 4 staff at the time of inspection. This is a preschool program and hours of operation are M-F 8:00am-5:00pm.

The department received an incident report via phone from this facility on 06/13/2024 for an incident that occurred at the facility on 06/11/2024 involving an incident requiring medical attention while in care, which was not reported timely to the department.

During the inspection LPA conducted (1) staff interview regarding the incident. LPA obtained documentation in the form of facility roster, attendance sheet, daily classroom schedule, Personnel report, C#1 file, Climber-Pickler Triangle Set structure description, photos, copy of the incident report provided to the parent and declarations.

During the visit LPA Perry observed the Climber-Pickler Triangle Set structure in the outdoor play yard where C#1 fell from (pictures were taken). Measurements were taken for Climber-Pickler Triangle Set structure and it was observed to be 28 by 32 in height. Based on manufactures information, it was determined that climbing structure is age appropriate. Manufacture label discloses that the piece of climbing structure can be used for ages 6 months to 6 years old or up to 132 pounds. Although facility has cameras, CEO Darian informed LPA Perry that facility would not be able provide the department with the footage. CEO Darian Williams signed a declaration explaining why video footage cannot be provided to the department. S#1 stated during outside time in the play yard, C#1 was climbing the Pickler Triangle Set structure, as C#1 was coming down the Pickler Triangle Set structure C#2 was playing with a wooden toy adjacent to the structure and as C#1 was coming down, C#1 fell, causing C#1 to land and bump C#1 cheek on a wooden toy that C#2 was
SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Staicy Perry
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2024
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 3
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: BRELLA HOLLYWOOD
FACILITY NUMBER: 198020953
VISIT DATE: 09/27/2024
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
playing with. It was at the same time C#1 was falling that C#2 was lifting the wooden toy. S#1 stated that she was steps away from C#1 and couldn’t reach child in time to prevent the injury.

Based on the information obtained on this date, no follow-up is necessary regarding the incident. The incident appears to be an unusual accident. Although the incident was determined that it was unusual, the facility did not report the incident to the department in a timely manner which poses a potential risk to the health and safety of the children in care.



The following deficiency listed on the attached LIC809 deficiency page is being cited per the California Code of Regulations, Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety.

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.

Appeal rights discussed and provided.

Exit interview was conducted with Rebecca Kelly.
SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Staicy Perry
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/27/2024 02:18 PM - It Cannot Be Edited


Created By: Staicy Perry On 09/27/2024 at 01:56 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: BRELLA HOLLYWOOD
FACILITY NUMBER: 198020953

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/04/2024
Section Cited
CCR
101212(d)(1)(c)

1
2
3
4
5
6
7
101212Reporting Requirements d)Upon...occurrence.. any... events specified..below, report shall be made ... by telephone...fax within the.. next working day and during... business hours...(1)Events reported..(C)Any unusual incident..This requirement is not met evidenced by
1
2
3
4
5
6
7
Director and assistant will review regulation on Reporting Requirements and sign off acknowldging their understanding via a declaration form to LPA by POC date .
8
9
10
11
12
13
14
Based on the information obtained unuslal incident that happend on June 11, 2024 was not reported to the department in a timely manner which poses a potential risk tot the health and safety of the children in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Staicy Perry
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2024


LIC809 (FAS) - (06/04)
Page: 3 of 3