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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191201764
Report Date: 05/01/2025
Date Signed: 05/01/2025 01:31:36 PM

Document Has Been Signed on 05/01/2025 01:31 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:ENCINO PRESBYTERIAN CHILDREN'S CENTERFACILITY NUMBER:
191201764
ADMINISTRATOR/
DIRECTOR:		TRAPANI, CATHLEENFACILITY TYPE:
850
ADDRESS:4963 BALBOA BOULEVARDTELEPHONE:
(818) 788-9442
CITY:ENCINOSTATE: CAZIP CODE:
91316
CAPACITY: 96TOTAL ENROLLED CHILDREN: 96CENSUS: 65DATE:
05/01/2025
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:10 AM
MET WITH:Cathleen Trapani, DirectorTIME VISIT/
INSPECTION COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA) Tatiana Bickham conducted an unannounced random annual inspection on 05/01/2025. LPA arrived at the facility at 8:10 AM. LPA met with Director Cathleen Trapani who guided LPA on tour of the facility. This is a preschool program licensed for 96 preschoolers. Facility consists of 8 classrooms, 6 classrooms are located on the first floor and 2 classrooms are located on the second floor. Hours of operation are Monday through Friday from 7:30am to 6:00pm.

All areas identified on the Facility Sketch were inspected. The following staff were present during this visit: Room #101: 2 staff with 6 preschoolers, Room #102: 2 staff with 6 preschoolers, Room #103: not in use, Room #104: 2 staff with 10 preschoolers, Room #105: 2 staff with 16 preschoolers, Room #106: 3 staff with 10 preschoolers, Room #204: not in use, and Room #203: 3 staff with 17 kindergartners.

Teacher/child ratios were not observed to be in accordance with Title 22 regulations. At 9:15 am during file review LPA observed staff in Room #105 was not a fully qualified teacher, making the classroom out of ratio. LPA observed 12 units in early childhood education but did not observe any units for Program/Curriculum. Per Director, Director was under the impression the staff having 12 units in early childhood education qualified the staff to be a fully qualified teacher. LPA informed Director 12 semester units or equivalent quarter units in early childhood education or child development are required to be a fully qualified teacher, per Title 22 regulation the units shall include courses that cover the general areas of child growth and development, or human growth and development; child, family and community, or child and family; and program/curriculum.

Staff names were recorded. All children were observed to be always under visual supervision of a teacher at all times. Page 1.

NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Tatiana Bickham
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2025
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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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)
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Document Has Been Signed on 05/01/2025 01:31 PM - It Cannot Be Edited


Created By: Tatiana Bickham On 05/01/2025 at 12:29 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: ENCINO PRESBYTERIAN CHILDREN'S CENTER
FACILITY NUMBER: 191201764

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216.3(b)(1)
Teacher-Child Ratio
(b) The licensee may use teacher aides in a teacher-child ratio of one teacher and one aide for every 15 children in attendance. (1) A ratio of one fully qualified teacher (as specified in Section 101216.1(c) and one aide for every 18 children in attendance in a preschool program is allowed when the aide meets the qualifications specified in Section 101216.2(d).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review, the licensee did not comply with the section cited above in which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2025
Plan of Correction
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At 9:15 am LPA observed during file review a teacher was not fully qualified per Title 22 regulations and therefore the classroom was out of ratio. At 9:25 am another teacher this is fully qualified was assigned to the classroom putting the classroom back into ratio. Per Director, the teacher will stay in the room for the remainder of the school year.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Raul Navarro
NAME OF LICENSING PROGRAM MANAGER:
Tatiana Bickham
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2025


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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: ENCINO PRESBYTERIAN CHILDREN'S CENTER
FACILITY NUMBER: 191201764
VISIT DATE: 05/01/2025
NARRATIVE
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Furniture and equipment were inspected for age appropriateness and good repair. Telephone service, heating, lighting and ventilation were evaluated. Children have their own cubby to store their belongings. Linens are taken home each week to be washed. Napping equipment (mats) were observed in a separate classroom. Per Director, the isolation area is located in the office. Age-appropriate sinks and toilets were inspected for availability and good repair in all restrooms.

General sanitation was observed. Availability of indoor drinking water, LPA also observed two water dispensers at the facility. Children bring their own water bottles. LPA observed during file review that the water was tested for lead in July 2023. LPA informed Director since they do not prepare food at the facility or provide drinking water from the faucets they do not have to test their water again.

Disinfectants, cleaning solutions, medication and other items that are dangerous to children, were inaccessible to children.

Food preparation areas and food storage areas are kept clean and are free of litter, rubbish, rodents, and/or any other vermin. All storage containers for solid waste, including moveable bins have tight-fitting covers that are kept on, and in good repair. Trash cans used to discard food have tight fitting lids or solid waste bags shall be discarded immediately after each meal. Food is not provided by the facility. The facility offers a hot lunch program 3 days out of the week that is delivered to the school, the other 2 days parent pack a sack lunch for the children. Parents also provides AM and PM snack for their children. First Aid supplies were observed. Per Director, medication is administered at the facility.

Outdoor playground equipment is in a safe condition, free of sharp, loose or pointed parts. The surface of the outdoor activity space is maintained in a safe condition and is free of hazards. All areas around or under high climbing equipment are cushioned with material that absorbs a fall. There is adequate shade in the play yard. Availability of outdoor drinking water was observed. LPA advised that no children shall be left without the supervision of a teacher at any time.

All floors were observed to be clean and safe. All materials accessible to children were observed to be toxic-free. There are no firearms stored on the premises. There are no pools or bodies of water at the facility.

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NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Tatiana Bickham
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025
LIC809 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: ENCINO PRESBYTERIAN CHILDREN'S CENTER
FACILITY NUMBER: 191201764
VISIT DATE: 05/01/2025
NARRATIVE
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A sample of children’s records were reviewed for Admission Agreement, LIC 700- Identification and Emergency Information, LIC 627- Consent for Medical Treatment, LIC 995A Notification of Parents’ Rights, LIC 613-Personal Rights, LIC 702-Health History, and LIC 701 Physicians Report, and Immunization Records.

A sample of staff records were reviewed for Education, LIC-501: Personnel Record, LIC 508-Criminal Record Statement, LIC 9052- Employee Rights, LIC503- Health Screening, Proof of immunization against measles, pertussis and influenza or influenza declination, TB clearance or risk assessment, LIC 9108- Statement Acknowledging Requirement to Report Child Abuse and current Mandated Reporter Training Certificate. There is at least one person trained in CPR and Pediatric First Aid present during this inspection.



Director was reminded that all adults 18 and over, 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated 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

Based on the LPA’s observations and records review, the following deficiencies listed on the attached LIC 809D (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety.

Exit interview conducted and report was reviewed with Director, Cathleen Trapani. A notice of site visit was given and must remain posted for 30 days.

Page 3.

NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Tatiana Bickham
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025
LIC809 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: ENCINO PRESBYTERIAN CHILDREN'S CENTER
FACILITY NUMBER: 191201764
VISIT DATE: 05/01/2025
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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 tools, please send them by email 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/tion-process.

Page 4.

NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Tatiana Bickham
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025
LIC809 (FAS) - (06/04)
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