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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197416054
Report Date: 03/05/2025
Date Signed: 03/05/2025 10:11:43 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/23/2024 and conducted by Evaluator Elicia Calvillo
COMPLAINT CONTROL NUMBER: 58-CC-20241223144802
FACILITY NAME:KIDS PARK NORTHRIDGE (SA)FACILITY NUMBER:
197416054
ADMINISTRATOR:ROSS, DAVIDAFACILITY TYPE:
840
ADDRESS:9056 TAMPA AVENUETELEPHONE:
(818) 998-5437
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY:25CENSUS: 3DATE:
03/05/2025
UNANNOUNCEDTIME BEGAN:
09:26 AM
MET WITH:Kayla Jimenez and Tania ReyesTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Staff forged authorized representative name on document.
INVESTIGATION FINDINGS:
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On 03/05/2025 at 09:25 AM, Licensing Program Analyst (LPA) Elicia Calvillo conducted an unannounced complaint investigation to deliver findings on the above-mentioned allegation. LPA identified self and met with Kayla Jimenez, Assistant Director and Tania Reyes Assistant Director, who guided analyst on a tour of the inside of the facility. LPA observed 3 Children upon arrival.

During today’s visit, LPA addressed the allegations that staff forged authorized representative name on document. Throughout the course of the investigation, LPA obtained the Child Care Facility Roster, interviewed staff, interviewed parents, and obtained copies of other pertinent documents..

Information provided by the Reporting Party indicates that staff forged authorized representative name on document.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rita Ramos
LICENSING EVALUATOR NAME: Elicia Calvillo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2025
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 2
Control Number 58-CC-20241223144802
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: KIDS PARK NORTHRIDGE (SA)
FACILITY NUMBER: 197416054
VISIT DATE: 03/05/2025
NARRATIVE
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Kayla Jimenez, Assistant Director stated that the staff do not forged authorized representative name on documents and that they follow their internal procedure to obtain signatures on documents.

When interviewing staff, staff did not make any disclosures regarding the allegations listed above.



When interviewing parents, parents did not make any disclosures regarding the allegations listed above.

No children were interviewed about the allegations listed above.

Based on LPA’s observations, interviews which were conducted, and record review, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated.

The Notice of Site Visit (LIC 9213) must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.

Exit interview was conducted with Kayla Jimenez, Assistant Director and Tania Reyes, Assistant Director including, but not limited to Provider Rights, Appeal Procedures and Agencies Consultative Role.
SUPERVISORS NAME: Rita Ramos
LICENSING EVALUATOR NAME: Elicia Calvillo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2