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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494575
Report Date: 05/12/2022
Date Signed: 05/12/2022 10:12:48 AM

Document Has Been Signed on 05/12/2022 10:12 AM - 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:
(818) 700-2821
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY: 46TOTAL ENROLLED CHILDREN: 46CENSUS: 12DATE:
05/12/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
07:58 AM
MET WITH:Jacqueline Lopez, TIME COMPLETED:
10:30 AM
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On 05/12/2022 at 7:58 a.m., Licensing Program Analyst (LPA) Denise Miranda arrived at Devonshire Infant Center located at 21203 Devonshire Street, Chatsworth, CA 91311, for the purpose of a Case Management-Plan of Correction Visit. LPA verified that all adults present at the facility have obtained criminal record clearances and are associated to the facility. The Facility operational hours is from: 6:30am to 6:00pm, Monday-Friday

At 8:00am LPA observed Teacher#3 and Teacher #4 arriving at the infant care facility.

At 8:02am LPA met with Ms. Jacqueline Lopez, Teacher, that has been designated as a responsible person of the facility. Ms. Lopez opened the gate of the infant facility and guided Analyst on a tour of the facility. During this visit, Director Assistant Ms. Amalia Gutierrez was not present at Infant facility.

At 8:03am LPA observed 12 infants children present being supervised by 4 staff members.



At 8:03am LPA observed that Ms. Teacher#3 and Teacher#4 had 4 infants at the Classroom#1, however LPA observed when Teacher#3 & #4 arrived at 8:00am at the facility.
Classroom#2: LPA observed 8 infants being supervised by 2 teachers (teacher#1 and Teacher#2)
During interview teacher #1 stated she arrived 6:30am and had only one child until teacher #2 arrived. Teacher#2 stated she arrived 7:15am.
Classroom#3: LPA observed no infant in care on this classroom.
From 6:30am to 8:00am, facility had 12 infants children present with 2 teachers (Teacher#1 and Teacher#2). In additional, parents are dropping off their infants at the main gate l
SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Denise Miranda
LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2022
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: 05/12/2022
NARRATIVE
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located by the outdoor space. One teacher needs go to leave the classroom and walk to the gate and pick up the infant, while one teacher stayed in classroom. (over ratio as well).

At 8:08a.m. LPA observed when Ms. Amalia Gutierrez arrived at the infant program facility.

On 05/11/2022, LPA conducted subsequent visit to deliver the final investigation complaint # 30-CC-20220324145344, the facility was cited in violation of Title 22: CCR Title 22, Division 12 Chapter 1 Article 02. Infant Care Center 111416.5 (b) – Staff-Infant Ratio and this is repeat violation.
Based on observed, review sign in & out and staff time sheet, it was determined that from the time 6:30am to 8:00am, 12 infants children present being supervised by 2 staff.

LPA will referral and Teacher Ms. Jacqueline Lopez, person in charge agreed to participate in the Technical Support Program (TSP).



LPA obtained copy of Sign in and out and time sheet staff of the day 5/12/2022.

In addition; A copy of this report must be provided to a parent or an authorized representative of all currently enrolled children and any newly enrolled child for the following 12 months.

The ACKNOWLEDGEMENT OF RECEIPT OF LICENSING REPORTS (LIC9224) shall be signed and kept in each of the children’s records. The report shall be provided no later than the next business day or the next day the child is in care. A copy of the form lic9224 was provided to Ms. Lopez.



This report shall be made available to the public upon request. LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.
An exit interview was conducted and a copy of this report, with appeal rights, civil penalty assessment – immediately repeat violation, along with the Notice of Site Visit were provided to Jacqueline Lopez, person in charge designated by Licensee/owner.
SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Denise Miranda
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
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Document Has Been Signed on 05/12/2022 10:12 AM - It Cannot Be Edited


Created By: Denise Miranda On 05/12/2022 at 09:18 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 INFANT CENTER
FACILITY NUMBER: 197494575

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/12/2022
Section Cited
CCR
101416.5(b)

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101416.5 Staff-Infant Ratio: (b) There shall be a ratio of one teacher for every four infants in attendance. This standard was not met based on evidence obtained through the interviews, revirew documents observations.


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Ms. Jaqueline Lopez, designated person in chage, provided a declaration (lic855 form), that she understand the Staff-Infant Ratio and stated that she will schedule
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LPA reviewed Sign in & out and staff timesheet for the day 5/12 and observed when 2 additional teachers arrived at 8:00am. From 6:30am to 8:00am, facility have 2 teachers with 12 infants in care. Faciltiy was over ratio. This poses an immediate Health and Safety risk to children in care.
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 more teachers, for ealy hours and will make sure the facility will be in compliance with the Staff-Infant Ratio. Ms. Lopez agreed to have TSP, LPA will referral to TSP team to contact the facility as soon as possible.

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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: 05/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022


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