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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197402051
Report Date: 05/01/2025
Date Signed: 05/01/2025 02:27:45 PM

Document Has Been Signed on 05/01/2025 02:27 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:AMESTOY ELEMENTARY SCHOOL ROOM 21FACILITY NUMBER:
197402051
ADMINISTRATOR/
DIRECTOR:		RYAN, HUGHFACILITY TYPE:
850
ADDRESS:1048 W. 149TH STREETTELEPHONE:
(310) 327-5592
CITY:GARDENASTATE: CAZIP CODE:
90247
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 14DATE:
05/01/2025
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:47 AM
MET WITH:Facility Representative (S1)TIME VISIT/
INSPECTION COMPLETED:
02:47 PM
NARRATIVE
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Licensing Program Analyst (LPA), Keyona Scott, conducted an unannounced 3 - Year Required Annual inspection to the Preschool Program located at Amestoy Elementary School on 05/01/2025 at 8:47 AM. LPA met with facility representative (S1) at 9:27 AM. LPA observed proper teacher to children ratios. At approximately 9:31 AM, LPA observed the following: fourteen (14) children to one (1) teacher and one (1) aid in dance class in the elementary school auditorium. LPA met with facility representative (S2) at 9:42 AM and was guided on a tour inside and outside of the school area utilized by the preschool. As a condition of employment, all individuals working or present at the facility that is operated by a school district shall obtain a criminal record clearance or criminal record exemption. The school district shall notify the Regional Office, if there is a change of status of an individual's criminal record clearance.

This is a Los Angeles Unified School District (LAUSD) preschool program that operates on the premise of LAUSD, Amestoy Elementary School. The preschool program utilizes classroom 22 on the elementary school premises. The preschool program is licensed to operate in classroom 21 at the elementary school, however, LPA was informed in August of 2024, the preschool program relinquished classroom 21 back to the elementary school and now utilizes classroom 22 for the preschool program. LPA observed classroom 21, in which is now used by the elementary school as a science center. LPA advised facility representative (S1) that LAUSD must send a written request to the El Segundo Child Care Regional Office on LIC 200A - Application For A Child Care Center License, officially requesting classroom change. LPA provided facility representative (S1) with a copy of LIC 200A for the school district to complete.
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NAME OF LICENSING PROGRAM MANAGER: Claudia Escobedo
NAME OF LICENSING PROGRAM ANALYST: Keyona Scott
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)
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)
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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: AMESTOY ELEMENTARY SCHOOL ROOM 21
FACILITY NUMBER: 197402051
VISIT DATE: 05/01/2025
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PHYSICAL PLANT
All areas identified on the Facility Sketch were inspected. The preschool program consists of one (1) classroom. LPA observed the following in the classroom: outlet covers over the electrical outlets not in-use, stored napping mats, cubbies with child's name to store each child's personal belongings brought from home, circle time carpet, table and chair sets and preschool restroom. LPA observed the following toys in the classroom: kitchen play set, blocks, arts and crafts materials, books and other age-appropriate playthings.

The facility was kept clean, neat and orderly. The restroom used by the preschool program is located in the preschool classroom. LPA observed two (2) toilets and one (1) sink in the preschool restroom. LPA observed the toilets and sink to be safe, sanitary and functional.

All poisons and hazardous items are stored and inaccessible to children in care. All floors are clean and safe. LPA observed the classroom and all kitchen areas and/or food preparation areas clean and free of litter and other hazardous items.

Outdoor play area is located on the elementary school play yard adjacent to the preschool classroom and the elementary school play yard adjacent to the T-K and Kindergarten classrooms. Per facility representative (S2), there are no play structures on the play yard adjacent to the preschool classroom. The outdoor play equipment for the preschool program is stored when not in use. The preschool program utilizes the play yard on the T-K and Kindergarten playground on Mondays, Wednesdays and Fridays due to the play yard has a play structure apparatus. LPA observed cushioned area under play apparatus to absorb a fall. The preschool program has scheduled outdoor play time to ensure the preschool children are not co-mingled with the elementary school children. LPA observed the outdoor play area to be in safe condition and free of sharp, loose or pointed parts. LPA did not observe any bodies of water to include in-ground pools on the facility premises. Drinking water is readily available both indoors and outdoors.

FACILITY RECORDS
There is at least one person present at facility that is trained in Pediatric CPR and First Aid. LPA advised facility representative that all preschool staff are to complete Mandated Reporter training every two years and certificate of completion is to be placed in each staff's individual file at the school site and made readily available for review upon Department's request. PAGE 2
NAME OF LICENSING PROGRAM MANAGER: Claudia Escobedo
NAME OF LICENSING PROGRAM ANALYST: Keyona Scott
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: 3 of 12
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: AMESTOY ELEMENTARY SCHOOL ROOM 21
FACILITY NUMBER: 197402051
VISIT DATE: 05/01/2025
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FACILITY RECORDS (continued)
LPA attempted to review personnel records during today's inspection, however, facility representative (S1) advised personnel files are not stored at elementary school and in the years she has been working at the school previous LPAs have not requested to review files. LPA advised facility representative that specific personnel files for the preschool program must be readily available upon Department's request. LPA provided facility representative with LIC 125 - Entrance Checklist - Child Care Centers and referred facility staff to review section, Records and other items to make available during inspection, Personnel records (All staff person). LPA advised the following personnel records are to be readily available during inspection:
  • Staff Qualifications
  • Proof of Immunization of Measles (MMR), Pertussis (Tdap), and Influenza (Flu) or Influenza Waiver
  • Current Pediatric CPR and First Aid Certification
  • TB Clearance or Risk Assessment
  • LIC 503 (Health Screening Report)
  • LIC 508 (Criminal Record Statement)
  • LIC 9108 (Statement Acknowledging Requirement to Report Child Abuse)
  • Mandated Reporter Training Certificate
  • LIC 9052 (Employee Rights)


LPA reviewed for the following Children's Record of four (4) children's files during today's inspection:
  • LIC 613A (Personal Rights)
  • Admission agreement
  • LIC 700 (Identification and Emergency Information)
  • LIC 701 (Physician's Report)
  • LIC 995 (Notification of Parents' Rights)
  • LIC 627 (Consent for Emergency Medical Treatment)
  • Immunization Record

LPA observed the following posted documents in classroom 22 during today's inspection:
  • Menus
  • PUB 269 - Child Passenger Restraint System Poster
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NAME OF LICENSING PROGRAM MANAGER: Claudia Escobedo
NAME OF LICENSING PROGRAM ANALYST: Keyona Scott
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 12
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: AMESTOY ELEMENTARY SCHOOL ROOM 21
FACILITY NUMBER: 197402051
VISIT DATE: 05/01/2025
NARRATIVE
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LPA advised facility representative that required documents to be posted are to be posted in a prominent, publicly accessible area at the facility. Per facility representative, parents do not have access to the preschool classroom. Facility representative advised LPA, the following required documents will be posted in the administration office at the elementary school:
  • Facility License
  • Menus
  • PUB 269 - Child Passenger Restraint System Poster
  • PUB 393 - Notification of Parents' Rights
  • LIC 610 - Emergency Disaster Plan
  • LIC 613A - Personal Rights


LPA provided facility represenatative with the following required documents during today's inspection:
  • PUB 393 - Notification of Parents' Rights (with current Regional Office address)
  • LIC 610 - Emergency Disaster Plan
  • LIC 613A - Personal Rights (with current Regional Office address)


LPA advised facility representative to move the following required posting document from the board in classroom 22 and place on the parent board in the administration office:
  • PUB 269 - Child Passenger Restraint System Poster

LPA reviewed the following documents during today's inspection:
  • Verification of Disaster and Fire Drills: Per review, last fire and disaster drills were conducted on 04/25/2025 and 04/23/2025.
  • Daily Activity Schedule
  • Sign In/Out Sheets


LPA provided facility representative with the following document to maintain on file and made readily available for review upon the Department's request:
  • LIC 9148 - Earthquake Preparedness Checklist
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NAME OF LICENSING PROGRAM MANAGER: Claudia Escobedo
NAME OF LICENSING PROGRAM ANALYST: Keyona Scott
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 12
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: AMESTOY ELEMENTARY SCHOOL ROOM 21
FACILITY NUMBER: 197402051
VISIT DATE: 05/01/2025
NARRATIVE
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LPA identified the following locations during today's inspection:
  • Medication Storage Area for Children Requiring Permissible Medical Services- Per facility representative, there are children currently enrolled that require permissible medical services.
  • Functioning Carbon Monoxide Detector, Smoke Alarm(s) and Fire Extinguisher(s)

The facility was operating in substantial compliance during today’s inspection on 05/01/2025. Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, no deficiencies cited.

The following was thoroughly discussed:
Facility representative was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

LPA referred facility representative to the Department website for lead: Lead Toxicity Prevention and Water Testing Information.

For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication. Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

Facility representative 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.



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NAME OF LICENSING PROGRAM MANAGER: Claudia Escobedo
NAME OF LICENSING PROGRAM ANALYST: Keyona Scott
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: 6 of 12
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: AMESTOY ELEMENTARY SCHOOL ROOM 21
FACILITY NUMBER: 197402051
VISIT DATE: 05/01/2025
NARRATIVE
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To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

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

Exit interview conducted and report was reviewed with facility representative (S1).
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NAME OF LICENSING PROGRAM MANAGER: Claudia Escobedo
NAME OF LICENSING PROGRAM ANALYST: Keyona Scott
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: 7 of 12