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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494575
Report Date: 03/30/2022
Date Signed: 03/30/2022 03:37:24 PM

Document Has Been Signed on 03/30/2022 03:37 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
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:DEVONSHIRE INFANT CENTERFACILITY NUMBER:
197494575
ADMINISTRATOR:MERADITH GRABLEFACILITY TYPE:
830
ADDRESS:21203 DEVONSHIRE STREETTELEPHONE:
8187002821
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY: 46TOTAL ENROLLED CHILDREN: 26CENSUS: 21DATE:
03/30/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Amalia Gutierrez, Director Assistant and Licensee Marian RanasinheTIME COMPLETED:
12:30 PM
NARRATIVE
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On 03/30/2022, 10:15am, Licensing Program Analyst (LPA) Denise Miranda conducted a Case Management for the purpose of the health and safety of the child care center.

LPM Miranda toured infant facility and observed 21 Infants under supervision of 9 staff.

Licensee, Ms. Marian arrived at facility at 9:45 am.

Review of Guardian associations of Criminal Background Clearance shows on staff member with a criminal background clearance that has not completed the background clearance still in process.

This observation will result in a Type A Citation with a Civil Penalty $500.

LPA advised this Type A citation will include a civil penalty of $500, $100 for each day the employee was present without a clearance. Allowing any person who is subject to a background check to work, reside or volunteer who does not have either a criminal record clearance or exemption. A civil penalty shall be assessed for a maximum of 5 days for the first violation. For subsequent violations within a 12 month period, a civil penalty shall be assessed for a maximum of 30 days. See California Health and Safety Code Section 1522(c)(1); 1568.09(c); 1569.17(c); and 1596.871(c).

LPA reviewed 11 Staff files and observed the files were not in compliance.

Director must comply with AB 633 as follows: Upon receipt by the licensee, licensee is to provide to parents/guardians the following: Copies of any licensing reports that document a Type A citation- this includes facility visits and substantiated complaint investigations; copy

SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Denise Miranda
LICENSING EVALUATOR SIGNATURE: DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: DEVONSHIRE INFANT CENTER
FACILITY NUMBER: 197494575
VISIT DATE: 03/30/2022
NARRATIVE
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of licensing documents pertaining to a conference conducted by a local licensing agency management representative and the licensee of this Child Care Center in which issues of noncompliance are discussed or copies of a summary of an accusation indicating the Department's intent to revoke the facility's license.

Copies of any of the above licensing documents issued to the licensee in the prior 12 months shall be provided to the parents/guardians of currently and newly enrolled child(ren) at the facility. Licensee will obtain an acknowledgement of the receipt of licensing reports form (LIC 9224) and maintain a signed copy in each child’s file.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following deficiency is being cited: (see next page, 809 D)

LPM Miranda informed Licensee and Director Assistant that this report dated 3/30/2022 documents Type A citation which shall be posted for 30 consecutive days as there is immediate risk to the health, safety, or personal rights of children in care.

An exit interview was conducted and a copy of this report, appeal rights and Notice of Site Visit was provided to Marian Renasinhe, Licensee.

SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Denise Miranda
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
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Document Has Been Signed on 04/22/2022 09:01 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 04/22/2022 08:40 AM


Created By: Denise Miranda On 03/30/2022 at 12:02 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
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: DEVONSHIRE INFANT CENTER
FACILITY NUMBER: 197494575

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/30/2022
Section Cited
CCR
101170(e)(1)

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101170 (e) (1) Criminal Record Clearance: e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed
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Licensee was informed that Tamara Buttler cannot be present in the facility until she obtains a criminal record clearance. A declaration was provided to LPA Miranda.
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facility:(1)Obtain a California clearance or a criminal record exemption as required by the Department.This requirement is not met as evidenced by: on 3/30/22 Based on Guardian. Ms. Tamara Butller has a pending status. LPA observed that individual providing care and supervision. This poses an immediately H&S to children in care.

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Director Assistant informed to Ms. Butler that she will allow to return after received her clearance.

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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:Claudia Escobedo
LICENSING EVALUATOR NAME:Denise Miranda
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022


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Document Has Been Signed on 03/30/2022 03:37 PM - It Cannot Be Edited


Created By: Denise Miranda On 03/30/2022 at 12:21 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: DEVONSHIRE INFANT CENTER
FACILITY NUMBER: 197494575

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/11/2022
Section Cited
CCR
101216(I)

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101216(l) Personnel Requirements (l) All personnel shall be informed of their rights pursuant to Sections 1596.881 and 1596.882 of the Health and Safety Code.
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Licensee agreed to submit the all 10 employee's files no later than 04/11/2022 via mail or drop off in person at DSS El Segundo Office.
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Based on records review. LPA reviewed 10 employee's files and they are incompleted. Which poses a potential Health or Safety, or personal rights risk to persons in care.
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LPA provided a copy of LIC311aa (Records to be Maintain at the Faciltiy - Child Care Centes).

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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:Claudia Escobedo
LICENSING EVALUATOR NAME:Denise Miranda
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022


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