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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191500117
Report Date: 10/22/2021
Date Signed: 10/22/2021 02:51:33 PM

Document Has Been Signed on 10/22/2021 02:51 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:CALVARY PRESCHOOLFACILITY NUMBER:
191500117
ADMINISTRATOR:MOLLY SPRAGGFACILITY TYPE:
850
ADDRESS:1050 FREMONT AVE.TELEPHONE:
(626) 799-0385
CITY:SOUTH PASADENASTATE: CAZIP CODE:
91030
CAPACITY: 134TOTAL ENROLLED CHILDREN: 134CENSUS: 59DATE:
10/22/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:47 PM
MET WITH:Assistant Director, Eloise MorinTIME COMPLETED:
03:00 PM
NARRATIVE
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An unannounced Case Management-deficiencies visit was conducted on today's date by Licensing Program Analyst (LPA) Bardo Baluyot to cite for deficiencies regarding a child's personal rights possibly being violated disclosed during the course of Director reporting a UIR on 10/1/2021. LPA met with Assistant Eloise Morin who guided the LPA on a tour of the facility.

Census: There were 59 preschoolers present throughout the seven pre school classrooms. Staff-child ratio was met.


The following is being cited in accordance to Title 22 of the California Code of Regulations and/or Health and Safety codes: Type B
  • To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature including but not limited to: interference with functions of daily living including eating, sleeping or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.

Please refer to 809 D for documentation of deficiencies.

Upon receipt, the Licensee shall post the Notice of Site Visit and the Licensing report. This report and the Notice of Site Visit shall be posted for 30 consecutive days. Failure to maintain posting as required will result in a $100 civil penalty.

An exit interview has been conducted with, and a copy of this report has been signed by and provided to Assistant Director, Eloise Morin. Appeal Rights have been provided and explained .
SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Bardo Baluyot
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 10/22/2021 02:51 PM - It Cannot Be Edited


Created By: Bardo Baluyot On 10/22/2021 at 02:24 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: CALVARY PRESCHOOL
FACILITY NUMBER: 191500117

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/22/2021
Section Cited
CCR
101223(a)(3)

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Personal Rights: To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature including but not limited to:interference with functions of daily living including eating, sleeping or toileting; or withholding of shelter, clothing,
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POC corrected: After all parties interviewed and Church and School Board and Legal team consulted during administrative review of incident: Staff involved was placed on administrative leave on 10/2/2021 and was subsequently dismissed on 10/8/21.
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medication or aids to physical functioning.

This requirement was not met as evidenced by UIR 10/1/21 and LPA's follow up interviews with Director and witnessing/reporting staff who made Administration aware of a child's personal rights possibly being violated while 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:Ana Chico
LICENSING EVALUATOR NAME:Bardo Baluyot
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2021


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