198021182-4-24-2023-33-CC-CGRN-CR7QKQ-20230424121444

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198021182
Report Date: 04/24/2023
Date Signed: 04/24/2023 12:15:03 PM

Document Has Been Signed on 04/24/2023 12:15 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:	EVERGREEN MONTESSORI ACADEMY		FACILITY NUMBER:	198021182
ADMINISTRATOR:	DR. KRISTINE VARDANYAN		FACILITY TYPE:	850
ADDRESS:	2038 EAST FOOTHILL BLVD		TELEPHONE:	(626) 460-0468
CITY:	PASADENA	STATE: CA	ZIP CODE:	91107
CAPACITY: 52	TOTAL ENROLLED CHILDREN: 52	CENSUS: 44	DATE:	04/24/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Dr. Kristine Vardanyan		TIME COMPLETED:	12:30 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	An announced pre-licensing site inspection was conducted today by Licensing Program Analyst (LPA) Crystal Green to inspect and measure facility for capacity determination. Licensing staff met with Site Director, Rosangelica Gonzalez and Applicant, Dr. Kristine Vardanyan. The applicant is requesting a Change of Ownership for an existing Preschool with Toddler Option Program. Facility location is currently operating as Evergreen Montessori Academy (198020782). The front of this facility is accessible from East Foothill Blvd. There is an additional entry which is accessible from Walnut Street. This is also where the facility parking lot is located. Per Director, the parents of toddler will use this entrance to avoid commingling. Parents of Preschoolers will also have access to this entrance. The existing facility has an approved waiver on file allowing toddlers to cross through the designed preschool yard in order to reach the entrance of the toddler classroom. At 10:27 AM, Licensing staff was guided through a tour of the existing preschool classrooms and toddler option program. This facility has a total of three classrooms: pre-primary, primary, and toddler classrooms. The facility was observed currently operating. LPA observed 20 children with 2 staff in the primary classroom, 14 children with 2 staff in the pre-primary classroom, and 10 toddlers with 2 staff in the toddler classroom. LPA observed 3 toilets and 3 sinks accessible between primary and pre-primary classroom available for the preschoolers. LPA observed 1 toilet and 1 sink available in the toddler classroom. LPA observed a changing table located in the toddler classroom however it was not located within arm’s reach of a sink. The exisiting facility has an approved waiver on file regarding the changing table. All toilets and sinks are in safe and sanitary operating conditions. LPA observed both programs to operate separately indoors. The Directors office will be used as the ill/isolation area with the child own cot and located right next to the director’s office will be the staff rest room for the ill child to use. Per Director, ill children will use the nearest restroom to the director's office. Cot is available for Ill children to rest if needed in the director’s office. Page 1 of 3

SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Crystal Green
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: EVERGREEN MONTESSORI ACADEMY	FACILITY NUMBER: 198021182
	VISIT DATE: 04/24/2023

NARRATIVE

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LPA observed the preschool emergency/first aid kit to be located in the preschool bathroom and the toddler program emergency/first aid located in the toddler classroom. Individual storage space was observed available for each child within each classroom. LPA observed cots available in each classroom. There are smoke detectors and fire extinguishers located throughout the facility.

Licensing staff was guided through the proposed outdoor activity space. The outdoor playground was inspected for safety, cushioning material, good repair and age appropriateness. LPA observed the preschool outdoor space to be physically separated from the toddler outdoor space. There is adequate shade available to children. LPA observed (1) water fountains available to children in care. Parents will provide sippy cups for their child. Facility will continue to use the Pasadena Unified School District food services for the children’s lunches. No transportation will be conducted by the facility.

Facility representative was reminded that all adults 18 and over responsible for administration or direct supervision of staff, persons who provides care and supervision to children, and staff who have contact with children, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

This facility plans to provide Incidental Medical Services – IMS. For IMS information, see PIN 22-02-CCP. A Plan of Operation that includes IMS must be submitted to the Department. 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

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 platform.

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SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Crystal Green
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: EVERGREEN MONTESSORI ACADEMY	FACILITY NUMBER: 198021182
	VISIT DATE: 04/24/2023

NARRATIVE

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

A fire clearance for the change of ownership was approved by Pasadena Fire Department. The capacity for the preschool with toddler option program will remain the same, forty (40) preschoolers and twelve (12) toddlers for a total capacity of fifty-two (52) children.

The applicant has submitted a waiver request regarding the toddlers changing table and access to the toddler entrance. LPA informed applicant that waivers are not automatically granted and will need to be review by the Regional Office for final approval. LPA obtained pictures of the changing table and play areas during this inspection.

An exit interview was conducted with Applicant and a signed copy of this report was provided.

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SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Crystal Green
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

LIC809 (FAS) - (06/04)

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