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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191500631
Report Date: 10/15/2025
Date Signed: 10/15/2025 10:00:26 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/09/2025 and conducted by Evaluator Nolan Tcheng
PUBLIC
COMPLAINT CONTROL NUMBER: 33-CC-20250909123510
FACILITY NAME:ST EDMUND'S NURSERY SCHOOLFACILITY NUMBER:
191500631
ADMINISTRATOR:LIZANNE WESTPHALFACILITY TYPE:
850
ADDRESS:1175 SAN GABRIEL BLVD.TELEPHONE:
(626) 792-7742
CITY:SAN MARINOSTATE: CAZIP CODE:
91108
CAPACITY:80CENSUS: 72DATE:
10/15/2025
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Liz Westphal - DirectorTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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9
No soft padding under balcony
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nolan Tcheng conducted an unannounced subsequent inspection of a complaint investigation. Upon arrival at 8:50am, LPA met with Director Liz Westphal, to whom the purpose of the inspection was explained. A tour of the facility was provided and census was obtained.

There are 72 children and 12 staff members.

During the course of the investigation, interviews were conducted with five staff members, nine children, and six parents. Documentation in the form of Class Rosters, Child Care Roster, and pictures were obtained.

Information from the complainant indicates that there is no soft padding underneath the balcony of a play structure.

REPORT CONTINUES PAGE 1 of 2
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Nolan Tcheng
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 33-CC-20250909123510
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: ST EDMUND'S NURSERY SCHOOL
FACILITY NUMBER: 191500631
VISIT DATE: 10/15/2025
NARRATIVE
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During inspection on 09/17/2025, LPA observed the playground area and took pictures of the structure and its surroundings. The “balcony” of the structure/play house was over an area of the playground are that had concrete below. There is a metal railing that has vertical bars along its entire width. The railing is approximately 2ft and 10inches tall, based on LPA measurements. The railing is secured to the structure/play house and outlines the whole balcony section of the structure.

Per staff interviews, teachers are stationed in different areas of the playground area to ensure supervision is provided. One teacher may be stationed in the sand/structure area while another teacher may be stationed on the hard top area. LPA discussed the safety of the structure with the Director of the facility. Director stated that the children are always being watched while outside and that the way the railings are built would make it difficult, that a child could not climb over the railing and potentially fall. LPA discussed that the possibility of a child climbing over and falling before a teacher is able to observe or react can still happen.

Based on LPAs observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. During review of the balcony and discussion with staff, there is no immediate danger to children in care. There has been no history of injury related to the allegation. Supervision is adequately provided. An Advisory Note is being provided to address the balcony area of the play structure and the installment of padding/cushioned material.

No deficiencies are being cited during today's inspection.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with Director Liz Westphal, at 9:55am. Copy of Report provided.

END OF REPORT PAGE 2 of 2

SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Nolan Tcheng
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/09/2025 and conducted by Evaluator Nolan Tcheng
PUBLIC
COMPLAINT CONTROL NUMBER: 33-CC-20250909123510

FACILITY NAME:ST EDMUND'S NURSERY SCHOOLFACILITY NUMBER:
191500631
ADMINISTRATOR:LIZANNE WESTPHALFACILITY TYPE:
850
ADDRESS:1175 SAN GABRIEL BLVD.TELEPHONE:
(626) 792-7742
CITY:SAN MARINOSTATE: CAZIP CODE:
91108
CAPACITY:80CENSUS: 72DATE:
10/15/2025
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Liz Westphal - DirectorTIME COMPLETED:
10:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff handle children in rough manner
Staff are verbally abusive
Staff isolate children to extensive periods
Staff did not observe child fall off tricycle
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Nolan Tcheng conducted an unannounced subsequent inspection of a complaint investigation. Upon arrival at 8:50am, LPA met with Director Liz Westphal, to whom the purpose of the inspection was explained. A tour of the facility was provided and census was obtained. There are 72 children and 12 staff members.

During the course of the investigation, interviews were conducted with five staff members, nine children, and six parents. Documentation in the form of Class Rosters, Child Care Roster, and pictures were obtained.

Information from the complainant indicates that staff handle children in a rough manner, are verbally abusive, and isolate children for extensive periods. Complainant also alleges lack of supervision resulted in staff not observing a child fall of a tricycle.

REPORT CONTINUES PAGE 1 of 2
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Nolan Tcheng
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 33-CC-20250909123510
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: ST EDMUND'S NURSERY SCHOOL
FACILITY NUMBER: 191500631
VISIT DATE: 10/15/2025
NARRATIVE
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During interviews, all staff were able to explain that redirection and speaking to the child about the situation were the facility’s discipline policy. All stated that there are no “time-outs” used at the facility. Staff #3 and #4 stated that a child may be asked to sit in a chair or be along side them until they are ready to rejoin the group.

There were no disclosures of staff speaking in verbally aggressive manners to children in care or handling children in a rough manner. Staff #1 explained “at the gate in the morning, sometimes the parents have to pass a child off to the teacher when they are crying. So sometimes it is helping prying fingers off the parent…but nothing more than that. Staff #3 stated that redirecting and guiding the child is suitable but grabbing is not appropriate.

Staff interviews all corroborated that during outside play time, staff will cover and supervise different areas of the playground. Staff #2 stated “on the playground we separate in different places so we are not standing together and we aren’t chit chatting. We are all by different sections.” There have been no disclosed issues with supervision for the facility.

Children interviews made no disclosures regarding the above allegations.

Parent interviews made no disclosures regarding the above allegations.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

No deficiencies are being cited during today's inspection.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with Director Liz Westphal, at 9:55am. Copy of Report provided.

END OF REPORT

SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Nolan Tcheng
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4