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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191597974
Report Date: 05/15/2025
Date Signed: 05/15/2025 10:53:34 AM

Document Has Been Signed on 05/15/2025 10:53 AM - 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:UNITED MOLOKAN CHRISTIAN ASSOC.PRESCHOOLFACILITY NUMBER:
191597974
ADMINISTRATOR/
DIRECTOR:		STEPHANIE PIVOVAROFFFACILITY TYPE:
850
ADDRESS:16222 E. SORIANO DRIVETELEPHONE:
(626) 336-5958
CITY:HACIENDA HEIGHTSSTATE: CAZIP CODE:
91745
CAPACITY: 25TOTAL ENROLLED CHILDREN: 13CENSUS: 12DATE:
05/15/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Mary Nevarov, DirectorTIME VISIT/
INSPECTION COMPLETED:
11:05 AM
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
On May 15, 2025, Licensing Program Analyst (LPAs) Monique Ayala and Diana Ortiz conducted an unannounced Annual/Random inspection. LPAs met with director, Mary who guided LPAs on a tour of the facility. LPAs observed 12 children in care with 3 staff. Per director there are 13 children enrolled. The facility's operating hours are Monday to Friday 8AM to 2:45PM.

The following classrooms were inspected: Classroom 1: 13 children with 3 staff. 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, including visual supervision. Licensed facility is within the conditions, limitations, and capacity specified on the license.

The classroom furniture and equipment was inspected for good repair, free of sharp, loose, or pointed parts. All indoor classrooms were inspected to ensure that the floors have a surface that is safe and clean. All toilets and washing facilities are in safe and sanitary operating conditions. All materials and surfaces accessible to children are toxic free.

The parents/guardians rotate on bringing snacks for children in care. LPA did not observe an updated menu. The snacks for today 05/15/2025 were not documented and the snacks for the following week were not documented on the menu.

NAME OF LICENSING PROGRAM MANAGER: Ana Chico
NAME OF LICENSING PROGRAM ANALYST: Monique Jessica Ayala
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2025
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 12
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)
Page: 2 of 12
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: UNITED MOLOKAN CHRISTIAN ASSOC.PRESCHOOL
FACILITY NUMBER: 191597974
VISIT DATE: 05/15/2025
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
LPAs observed that there are functioning smoke detector in the facility. LPAs observed a fully charged fire extinguisher, the fire extinguisher is 13 days past servicing. LPAs informed the director to contact their local fire department for fire extinguisher servicing. Emergency disaster drill was last conducted on 03/12/2025. LPAs did not observe a carbon monoxide.

Outdoor playground 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, swings, slides, and similar equipment are cushioned with material that absorbs a fall. LPAs observed spider-webs on equipment, LPAs observed the bottom step of the climbing structure to be worn out and there are portions of the sides of the step no longer have rubber material. LPAs observed a Trader Joe's multipurpose cleaner that was uncovered near the children's tables outside (LPAs obtained images). LPAs also observed adult size scissors hanging on the chained link fence in the same area the multipurpose cleaner was observed. LPAs advised director, to place the scissors in a more secure place as they could pose a danger to children should they fall or a child is able to reach. LPAs observed a long wooden log near the garden beds that per director is a balancing beam. LPAs informed director that the beam needs to sanded down and the staples need to be removed.



Sign in and out sheets were reviewed to ensure that the person who signs the child in and out uses their full legal signature and records the time of the day. LPAs reviewed staff records, staff files were not complete.

Children’s Records were reviewed to ensure that Identification and Emergency form and a medical assessment are on file. Criminal Records Clearance for adults and verification of CPR/First Aid and health preventative practices documentation was reviewed.

SB792 (Immunization Requirements for Staff and Employees) was discussed with the Director. The Director and staff do currently have immunization documentation.

NAME OF LICENSING PROGRAM MANAGER: Ana Chico
NAME OF LICENSING PROGRAM ANALYST: Monique Jessica Ayala
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
LIC809 (FAS) - (06/04)
Page: 3 of 12
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: UNITED MOLOKAN CHRISTIAN ASSOC.PRESCHOOL
FACILITY NUMBER: 191597974
VISIT DATE: 05/15/2025
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
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.

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

CCC COMPLETED TESTING AND NO LEAD EXCEEDANCES: Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test. For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1- CCP). LPAs verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP

LPAs advised the licensee to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov.



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.
NAME OF LICENSING PROGRAM MANAGER: Ana Chico
NAME OF LICENSING PROGRAM ANALYST: Monique Jessica Ayala
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
LIC809 (FAS) - (06/04)
Page: 4 of 12
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: UNITED MOLOKAN CHRISTIAN ASSOC.PRESCHOOL
FACILITY NUMBER: 191597974
VISIT DATE: 05/15/2025
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
Director was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Based on the LPAs’s observations and records reviews, 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 and safety.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

An exit interview was conducted, and a copy of the report was provided to director along with appeal rights.

NAME OF LICENSING PROGRAM MANAGER: Ana Chico
NAME OF LICENSING PROGRAM ANALYST: Monique Jessica Ayala
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
LIC809 (FAS) - (06/04)
Page: 5 of 12
Document Has Been Signed on 05/15/2025 10:53 AM - It Cannot Be Edited


Created By: Monique Jessica Ayala On 05/15/2025 at 10:18 AM
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: UNITED MOLOKAN CHRISTIAN ASSOC.PRESCHOOL
FACILITY NUMBER: 191597974

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.954
Licensure Requirements
Every licensed child day care center shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in there was no operable carbon monoxide at the licensed facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2025
Plan of Correction
1
2
3
4
Director, will obtain a operable carbon monoxide by POC date (05/19/2025).
Type B
Section Cited
CCR
101238.4(d)
Storage Space
(d) Combustibles, cleaning equipment and cleaning agents shall be stored in an area separate from food supplies in a locked cabinet or in a location inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in LPAs observed an open cleaning solution near the children's tables outside which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2025
Plan of Correction
1
2
3
4
Director has removed the cleaning solution and placed in an inaccessible area.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Ana Chico
NAME OF LICENSING PROGRAM MANAGER:
Monique Jessica Ayala
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2025


LIC809 (FAS) - (06/04)
Page: 6 of 12
Document Has Been Signed on 05/15/2025 10:53 AM - It Cannot Be Edited


Created By: Monique Jessica Ayala On 05/15/2025 at 10:18 AM
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: UNITED MOLOKAN CHRISTIAN ASSOC.PRESCHOOL
FACILITY NUMBER: 191597974

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101239(f)(1)
Fixtures, Furniture, Equipment and Supplies
(f) Solid waste shall be stored, located and disposed of in a manner that will not transmit communicable diseases or odors, create a nuisance, or provide a breeding place or food source for insects or rodents. (1) All containers used for storage of solid wastes, including moveable bins, shall have a tightfitting cover that is kept on; shall be in good repair; and shall be leakproof and rodent-proof.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in LPAs obsevred children throw their snack away in trash can that does not have a tight fitted lid which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2025
Plan of Correction
1
2
3
4
Director will obtain tight fitted lids for trash that contains food.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

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 Staff #1 and Staff #3 do not have a mandated reported on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2025
Plan of Correction
1
2
3
4
Director and staff #3 will obtain a mandated reporter certificate by POC datw 05/30/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Ana Chico
NAME OF LICENSING PROGRAM MANAGER:
Monique Jessica Ayala
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2025


LIC809 (FAS) - (06/04)
Page: 7 of 12
Document Has Been Signed on 05/15/2025 10:53 AM - It Cannot Be Edited


Created By: Monique Jessica Ayala On 05/15/2025 at 10:18 AM
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: UNITED MOLOKAN CHRISTIAN ASSOC.PRESCHOOL
FACILITY NUMBER: 191597974

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

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 obtaining immunizations records for Staff #1 to Staff #3 which poseses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2025
Plan of Correction
1
2
3
4
Director and staff will obtain immunizatio records by POC date of 5/30/25.
Type B
Section Cited
CCR
101215.1(m)
Child Care Center Director Qualifications and Duties
(m) A child care center director shall complete 16 hours of health and safety training if necessary pursuant to Health and Safety Code Section 1596.866.

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 obtaining health and safety training which poseses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/06/2025
Plan of Correction
1
2
3
4
Director wil obtain health and safety training by POC date of 5/30/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Ana Chico
NAME OF LICENSING PROGRAM MANAGER:
Monique Jessica Ayala
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2025


LIC809 (FAS) - (06/04)
Page: 8 of 12
Document Has Been Signed on 05/15/2025 10:53 AM - It Cannot Be Edited


Created By: Monique Jessica Ayala On 05/15/2025 at 10:18 AM
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: UNITED MOLOKAN CHRISTIAN ASSOC.PRESCHOOL
FACILITY NUMBER: 191597974

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(g)(1)
Personnel Requirements
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

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 not obtaining turberculosis test which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2025
Plan of Correction
1
2
3
4
Staff #3 and staff #4 will obtain a tuberculosis test by POC date of 5/30/25.
Type B
Section Cited
CCR
101216(l)(1)(B)
Personnel Requirements
(B) A copy of the signed LIC 9052 (11/94) shall be kept in the employee's personnel record.

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 Staff #1, Staff #3 and Staff #4 do not have a signed LIC9052 on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2025
Plan of Correction
1
2
3
4
Director will ensure that the above staff have a signed LIC9052 in their file by POC datw (05/19/2025).
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Ana Chico
NAME OF LICENSING PROGRAM MANAGER:
Monique Jessica Ayala
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2025


LIC809 (FAS) - (06/04)
Page: 9 of 12
Document Has Been Signed on 05/15/2025 10:53 AM - It Cannot Be Edited


Created By: Monique Jessica Ayala On 05/15/2025 at 10:18 AM
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: UNITED MOLOKAN CHRISTIAN ASSOC.PRESCHOOL
FACILITY NUMBER: 191597974

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101227(a)(6)
Food Service
(6) Menus shall be in writing and shall be posted at least one week in advance in an area accessible for review by the child's authorized representative. Copies of the menus as served shall be dated and kept on file for at least 30 days. Menus shall be made available for review by the child's authorized representative and the Department upon request.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in LPAs observed the snack menu that was not completed with today's snack (05/15/2025) and did not observe the follwing week's snack manu which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2025
Plan of Correction
1
2
3
4
Director will compelte snack menus one week in advance and submit proof to LPA by POC date (05/19/2025)
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.
Ana Chico
NAME OF LICENSING PROGRAM MANAGER:
Monique Jessica Ayala
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2025


LIC809 (FAS) - (06/04)
Page: 10 of 12