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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197406835
Report Date: 12/10/2025
Date Signed: 12/10/2025 02:51:09 PM

Document Has Been Signed on 12/10/2025 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:NESTLE AVENUE ELEMENTARY SCHOOL, ST. PKFACILITY NUMBER:
197406835
ADMINISTRATOR/
DIRECTOR:		GOMEZ, IBIA M.FACILITY TYPE:
850
ADDRESS:5060 NESTLE AVENUE #7TELEPHONE:
(818) 342-6148
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 14DATE:
12/10/2025
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Jennifer DiLorenzo, Designee and Socorro Martinez, AideTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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On 12/10/2025 at 10:15 AM, Licensing Program Analysts (LPAs) Brittanee Cleveland and Christina Nunez met with facility aide Socorro Martinez, for the purpose of conducting a required 3-year visit. LPAs also met with facility designee and school Principal, Jennifer DiLorenzo. LPAs toured/inspected the facility. Facility is located at an LAUSD school in Room 7 that operates from 7:30 AM until 4:00 PM Monday through Friday. The facility follows the LAUSD school calendar. At the time of inspection, there were 14 children in care, one director, and 2 staff in the classroom.

The teacher for the day is a substitute. The aide works in the classroom daily. At the time of inspection, Martinez’s background clearance had not transferred in the Guardian system. LPAs have issued a Type B violation for the clearance to be updated.

All areas identified on the Facility Sketch were inspected.

During the inspection, furniture and equipment were inspected for age appropriateness and good repair. Telephone service, heating, lighting and ventilation were evaluated. At the time of inspection, LPAs observed individual cubbies for children’s personal belongings.

Age-appropriate sinks and toilets were inspected for availability and good repair in the restrooms. General sanitation was observed. Availability of indoor drinking water was observed in classrooms. Per Director, children bring their own water bottle daily, which is labeled with child’s name.

Disinfectants, cleaning solutions, medication and other items that are dangerous to children, were inaccessible to children. Director states that poisons are locked in the main office and inaccessible to children. Carbon monoxide and smoke detectors were observed and are operable. --- Page 1

NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Brittanee Cleveland
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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: NESTLE AVENUE ELEMENTARY SCHOOL, ST. PK
FACILITY NUMBER: 197406835
VISIT DATE: 12/10/2025
NARRATIVE
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All food storage areas are kept clean and are free of litter, rubbish, rodents, and/or any other vermin. All storage containers for solid waste, including moveable bins shall have tight-fitting covers that are kept on, and in good repair. Trash cans used to discard food have tight fitting lids or solid waste bags shall be discarded immediately after each meal. The facility has a food service for lunch and snacks for the room. Children are able to bring their own lunch from home, which is kept in child’s individual lunch bag.

Outdoor playground equipment is in a 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. LPAs advised that no children shall be left without the supervision of a teacher at any time.

All floors were observed to be clean and safe. All materials accessible to children were observed to be toxic-free.

Per Director, there are no firearms stored on the premises. LPA did not observe pools or bodies of water at the facility.

There is at least one person trained in CPR and Pediatric First Aid present during this inspection.

LPA also reviewed staff records. LAUSD keeps record of all employees’ certifications. Staff present did have proof of the AB 1207 Mandated Reporter Training certificate on file. Staff did have proof against measles and pertussis.

Children’s Records were reviewed. Inspection of required forms was made and documented on the LIC 857. Children's roster was reviewed and is current. Sign-In and Sign-Out sheets were reviewed. Children present were signed in.

Menus are posted in advance where it is visible by the child's authorized representative. Menus for the past 30 days are available upon request.

Disaster drill log was available, last drill was conducted on 12/09/2025.

First Aid supplies were observed in the facility. The facility was observed to be equipped with an isolation area for any child who becomes ill and it is located in the nurses office. --- Page 2

NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Brittanee Cleveland
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2025
LIC809 (FAS) - (06/04)
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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: NESTLE AVENUE ELEMENTARY SCHOOL, ST. PK
FACILITY NUMBER: 197406835
VISIT DATE: 12/10/2025
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.

Licensee [or 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.

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).
LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP. PIN 22-05-CCP
• CCC TESTING DEADLINE HAS NOT PAST

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

LPA discussed the safe sleep regulations with licensee [or facility representative] and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee [or facility representative] of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.-- Page 3
NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Brittanee Cleveland
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2025
LIC809 (FAS) - (06/04)
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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: NESTLE AVENUE ELEMENTARY SCHOOL, ST. PK
FACILITY NUMBER: 197406835
VISIT DATE: 12/10/2025
NARRATIVE
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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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) 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/.

Licensee [or 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.

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

Exit interview conducted and report was reviewed with the facility representative and aide, Socorro Martinez.

--- Page 4.

NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Brittanee Cleveland
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/10/2025 02:51 PM - It Cannot Be Edited


Created By: Brittanee Cleveland On 12/10/2025 at 02:37 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: NESTLE AVENUE ELEMENTARY SCHOOL, ST. PK
FACILITY NUMBER: 197406835

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.871(c)(1)(A)
Administration of Child Day Care Licensing
Subsequent to initial licensure, a person specified in subdivision (b) who is not exempt from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification, pursuant to subdivision(f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2025
Plan of Correction
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LPAs have requested a copy of LIC9182 for the transfer of background clearance.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Raul Navarro
NAME OF LICENSING PROGRAM MANAGER:
Brittanee Cleveland
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2025


LIC809 (FAS) - (06/04)
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