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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494365
Report Date: 04/18/2023
Date Signed: 04/18/2023 03:22:07 PM

Document Has Been Signed on 04/18/2023 03:22 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
L.A. DAYCARE-NO.WEST, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:PACE - OCEANSIDE LEARNING ACADEMYFACILITY NUMBER:
197494365
ADMINISTRATOR:VARGA, JOHNFACILITY TYPE:
850
ADDRESS:682 BROADWAY STREETTELEPHONE:
(424) 280-4090
CITY:VENICESTATE: CAZIP CODE:
90291
CAPACITY: 28TOTAL ENROLLED CHILDREN: 28CENSUS: DATE:
04/18/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Davida Brown/ LaShaye DavisTIME COMPLETED:
03:30 PM
NARRATIVE
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 On 04/17/2023 Licensing Program Analyst( LPA) Doris Whitmore conducted an unannounced case management. After conducting interviews facility failed to report an Unususal Incident that took place on 01/11/2023. Police were called after parent went in the school requesting to see his daughter. An internal UIR Report was done but not submitted to Community Care Licensing.
SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Doris Whitmore
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2023
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 2
Document Has Been Signed on 04/18/2023 03:22 PM - It Cannot Be Edited


Created By: Doris Whitmore On 04/18/2023 at 02:39 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: PACE - OCEANSIDE LEARNING ACADEMY
FACILITY NUMBER: 197494365

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/02/2023
Section Cited
CCR
101212(d)(1)(c)

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Upon the occurrence, during the operation of child care center of any of the events specified in (d) (1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information specified in (d)(2) bellow shall be submitted to the Department within
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Have the Administrative Staff view videos on the website for Reporting Requirements by 05/02/2023 sending to the LPA of what their take away is from the videos
and to report any Unusual Incidents wwww.ccld.ca.gov
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seven days following the occurence of such event.
Events reported shall include the following: Any unusual incident or child absence that threatens the physical or emotional health or safety of any child.
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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.
SUPERVISOR'S NAME:Karren Starks
LICENSING EVALUATOR NAME:Doris Whitmore
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2023


LIC809 (FAS) - (06/04)
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