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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191502175
Report Date: 02/03/2022
Date Signed: 02/03/2022 04:32:31 PM

Document Has Been Signed on 02/03/2022 04:32 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:PLAY FACTORYFACILITY NUMBER:
191502175
ADMINISTRATOR:LANA SHIFFLETFACILITY TYPE:
850
ADDRESS:9723 GARIBALDI AVE.TELEPHONE:
(626) 285-9223
CITY:TEMPLE CITYSTATE: CAZIP CODE:
91780
CAPACITY: 55TOTAL ENROLLED CHILDREN: 55CENSUS: 53DATE:
02/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Lana ShiffletTIME COMPLETED:
04:45 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) Cynthia Reyes, conducted an unannounced 1 year annual inspection and Increase in capacity Inspection on this date. LPA met with Director, Lana Shifflet and a copy of the Entrance Checklist for Child Care Centers form (LIC 125) was provided. A risk assessment was conducted prior to entering the facility. Due to COVID- 19 precautionary measures were taken during the entire inspection and all individuals present during this inspection wore appropriate personal protective equipment. This is a preschool program which the operating hours are from 7AM to 6PM, Monday through Friday.

9:15 AM The tour began at the gate located at the back of the church where LPA observed where parents will take there child and their own temperature and use hand sanitizer. The parent will then enter the gate and stop at a table where they will sign their child in/out and then will take their child to wash their hands before handing them off to the staff at their class room door. The staff will do health checks of the child when they enter the class room. Parents will not enter the class rooms, unless they request to enter the class room, which at that time all precautionary measures will be taken for that individual entering. Facility staff will walk the child out at pick up time. LPA observed by the sign in/out area, Covid postings and clean and dirty pens
All licensing forms and Covid-19 posters are housed on a board with glass along the walk way to the sign in/out sheets. Facility was observed to be adhering to local public health guidelines. (According to CDC guidelines, children under the age of (2) are not required to wear masks.)

All areas identified on the Facility Sketch were inspected. The following was observed during the tour of the preschool class rooms. LPA observed and measured the new room requested for the increase in capacity, which will be called the Busy Bees (Previously the church name sunshine room). Measurements for this room accommodate capacity of 19 children only. This room is located next to the Kitchen. Next to the other side of the kitchen is two bathrooms each has 1 toilet and 1 sink (Total 2 toilets and 2 sinks).
PAGE 1 OF 5
SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Cynthia Reyes
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2022
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 7
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: PLAY FACTORY
FACILITY NUMBER: 191502175
VISIT DATE: 02/03/2022
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
Continuing on the tour of the class rooms, LPA inspected the Rainbow room which the director states is only designated for Napping. Right outside this room is the sign in/out table and next to that is a gate where parents will only use early in the morning to enter and the staff rest room is outside that gate as well. Next to that gate is a door that leads to the entrance to 3 class rooms (Lady bugs/caterpillars and busy bees). The entrance area of these rooms are the children's cubbies and hanging hooks of children's belongings. The first door on the left of the entrance is one large room divided into 2 rooms. The front room is the Caterpillars and the back part of the room is called the Lady Bugs (Room is divided by floor to ceiling shutter screen). The room on the right side of the entrance is formally named the Busy bees and will be changed to the Grasshoppers. Their is a bathroom in the caterpillars room with 1 toilet and 1 sink. Their is also a changing table with a portable sink within arms reach. In the Grasshoppers room is a bathroom with 1 toilet and 1 sink.
LPA was then lead to the Main office door and down the hall is the Dragonflies class room and next door is the Butterflies class room. In the hall of these calls room is 2 bathrooms each with 1 toilet and 1 sink and in between these bathrooms is 1 sink. (Total 2 toilets and 3 sinks).

Teacher-child ratios were observed to be in accordance with Title 22 Regulations. Staff names were recorded. All children were observed to be under supervision & observation, including visual supervision, of a teacher at all times. The licensed facility is within the conditions, limitations, & capacity specified on the license.

Furniture and equipment were inspected for age appropriateness and good repair. Telephone service, heating, lighting and ventilation were evaluated. Preschool children have their own cubby to store their personal belongings. LPA observed napping equipment/bedding and was inspected to be in good condition, appropriate storage and cleanliness. Parents bring linens and take home weekly to wash. The ill isolation area is located in the main office. Staff rest room is located down the hall from the main office which the ill child will use only.

Disinfectants, cleaning solutions, medication and other items that are dangerous to children, were observed to be inaccessible to children. Lana states there are no poisons located at the facility. Carbon monoxide and smoke detectors were observed and are operable. Lana stated there are no weapons or firearms on the premises.
PAGE 2 OF 5
SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Cynthia Reyes
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022
LIC809 (FAS) - (06/04)
Page: 2 of 7
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: PLAY FACTORY
FACILITY NUMBER: 191502175
VISIT DATE: 02/03/2022
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
Menus were reviewed to ensure that they are being posted at least one week in advance and visible to an authorized representative. The facility provides breakfast, lunch and PM snack. All kitchen, food preparation, and storage areas are clean, free of litter, rubbish, and rodents/vermin. All food is protected from contamination, and LPA inspected that any contaminated food is discarded immediately. There is drinking water available indoors and outdoors by use of pitcher/jugs and disposable cups. Children also bring their own labels water bottles. All storage containers for solid waste, including moveable bins, have tight fitting covers on and are in good repair. The licensee takes measures to keep the facility free of flies, other insects and rodents. Menus for the past 30 days are available upon request. Snacks and food were reviewed for availability, quantity and appropriateness to children in care.

The outdoor playground was inspected and the play equipment is in 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, slides, and similar equipment are cushioned with material that absorbs a fall. There is adequate shade in the play yard. LPA did not observe any bodies of water on the premises. The Preschool play yard is separated by a gate from the parking area.



Lana 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.

Children’s Records were reviewed for completeness; Inspection of required forms was made and documented on the LIC 857. LPA also reviewed Staff record, which were documented on the LIC 859. Staff present had proof against TB, measles, pertussis, and influenza, as well as current Mandated reporter.

There is at least one person trained in CPR and Pediatric First Aid present during this inspection. Pediatric CPR & First Aid is documented for staff who have it and is current for the Director & Assistant Director, both on Exp. 10/10/2022 and 10/16/2022.

PAGE 3 OF 5
SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Cynthia Reyes
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022
LIC809 (FAS) - (06/04)
Page: 3 of 7
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: PLAY FACTORY
FACILITY NUMBER: 191502175
VISIT DATE: 02/03/2022
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
Children's roster was reviewed and is current and number of total enrolled at this time was documented. Sign-In and Sign-Out sheets were reviewed. Children present were signed in correctly and accounted for on this date. Disaster drill log was available and posted visibly for all to see. The last drill was conducted on 01/31/2022.

Medication: This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. 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

First Aid supplies were observed in the classroom in a cabinet. According to Staff, medication is only administered to a child when accompanied with a doctor's note and is stored in the classroom.

Update: Effects of Lead Exposure and the following Provider Information Notices (PINs) Required Lead Testing: PIN 20-01 CCP Effects of Lead Exposure, and Guardian User Account Access - PIN 20-20-CCLD. were discussed.

AB1207 Mandated Child Abuse Reporting – On or before March 30, 2018 any person who works in a child care facility shall complete the training and renew the training every 2 years. Website provided: https://www.mandatedreporterca.com/training/child-care-providers.

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/process.

PAGE 4 OF 5
SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Cynthia Reyes
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022
LIC809 (FAS) - (06/04)
Page: 4 of 7
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: PLAY FACTORY
FACILITY NUMBER: 191502175
VISIT DATE: 02/03/2022
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
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.

LPA Reyes informed Director Lana Shifflet that this report dated 02/03/2022 document(s) one Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Reyes informed the Director Lana Shifflet to provide a copy of this licensing report dated 02/03/2022 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Based on measurements taken today, capacity for the increase in the preschool program, will be 19 as requested, for a total capacity of 74. Fire clearance has been approved on 01/19/22 for a total of 74. LPA requested waiver for the portable sink.



4:45 PM Exit interview conducted and report was reviewed with Director, Lana Shifflet. A notice of site visit was given and must remain posted for 30 days. Consultation was conducted on this date.

Helpful Resources:


Reporting Unusual Incidents: MPROIncidentReports@dss.ca.gov. CCL Resources for Parents & Providers: https://ccld.childcarevideos.org/ Provider Information Notices (PINs): https://www.cdss.ca.gov/inforesources/community-care-licensing/policy/provider-information-notices/child-care

Access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov.

END OF REPORT: PAGE 5 OF 5

SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Cynthia Reyes
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022
LIC809 (FAS) - (06/04)
Page: 5 of 7
Document is an Amendment of Original Document on 02/07/2022 08:33 AM


Created By: Cynthia Reyes On 02/03/2022 at 03:13 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: PLAY FACTORY
FACILITY NUMBER: 191502175

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101170(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in one out of nine staff file review which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/04/2022
Plan of Correction
1
2
3
4
Director states will have staff member fingerprint cleared by tomorrow 02/04/2022.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Christina Gabelman
LICENSING EVALUATOR NAME:Cynthia Reyes
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2022


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 02/03/2022 04:32 PM - It Cannot Be Edited


Created By: Cynthia Reyes On 02/03/2022 at 03:13 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: PLAY FACTORY
FACILITY NUMBER: 191502175

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101170(e)(2)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 101170(f) or

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in one out of nine staff file review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/04/2022
Plan of Correction
1
2
3
4
Director handed LPA all requiered documents to associate the staff member. Director states she Fax copies of all documents on 08/24/2021. Association will be completed by 02/04/2022.
Type B
Section Cited
CCR
101216(g)(2)
Personnel Requirements
(2) Each person specified in (g) above shall have a health-screening report signed by the person performing the screening. This report shall indicate the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in two out of nine staff file review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/18/2022
Plan of Correction
1
2
3
4
Director states will submit copies of the LIC 503 for both staff members by the POC date.
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:Christina Gabelman
LICENSING EVALUATOR NAME:Cynthia Reyes
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2022


LIC809 (FAS) - (06/04)
Page: 7 of 7