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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494574
Report Date: 01/04/2024
Date Signed: 01/04/2024 02:08:00 PM

Document Has Been Signed on 01/04/2024 02:08 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:DEVONSHIRE PRESCHOOLFACILITY NUMBER:
197494574
ADMINISTRATOR:JACQUELINE SORIA LOPEZFACILITY TYPE:
850
ADDRESS:21203 DEVONSHIRE STREETTELEPHONE:
(818) 700-2821
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY: 60TOTAL ENROLLED CHILDREN: 20CENSUS: 17DATE:
01/04/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Jacqueline Soria Lopez-DirectorTIME COMPLETED:
01:20 PM
NARRATIVE
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On 1/4/2023, Licensing Program Analyst (LPA) Suzette Ornelas conducted an unannounced case management inspection for the purpose of deficiencies observed during a complaint investigation for complaint control # 58-CC-20230929121459. Upon arrival LPA was greeted by and observed 17 children and 3 adults.

LPA Ornelas investigated complaint control #58-CC-20230929121459. According to the complaint investigation report received on 9/29/2023, facility is operating out of ratio.

Based on interview conducted with Director, Director was not on site for approximately five months; therefore, was not present during the time the complaint was received by the department.

LPA explained to the Director that the name of the child care center director, and any fully qualified teacher(s) designated to act in the child care center director's absence, shall be reported to the Department within 10 days of a change of child care center director or designee(s). Director understands and will comply.

The following Type B deficiencies is/are being cited on 1/4/2023 in accordance to Title 22 of the California Code of Regulations:
101212(b)

Please refer to 809D for cited deficiencies.

A copy of this report, notice of site visit, and appeal rights were provided. 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 director.
SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Suzette Ornelas
LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2024
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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Document Has Been Signed on 01/04/2024 02:08 PM - It Cannot Be Edited


Created By: Suzette Ornelas On 01/04/2024 at 11:55 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: DEVONSHIRE PRESCHOOL
FACILITY NUMBER: 197494574

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/04/2024
Section Cited
CCR
101212(b)

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101212(b)Reporting Requirements (b) The name of the child care center director, and any fully qualified teacher(s) designated to act in the child care center director's absence, shall be reported to the Department within 10 days of a change of child care center director or designee(s). This requirement is not met as evidence by:
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Director returned to oversee faciilty as of October 2, 2023.
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Based on observations and interviews, interim director was not reported to the the department for the 5 months that the director was not present, which poses a potential health, safety or personal rights risk to persons in care.
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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:Betty Bell
LICENSING EVALUATOR NAME:Suzette Ornelas
LICENSING EVALUATOR SIGNATURE:
DATE: 01/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2024


LIC809 (FAS) - (06/04)
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