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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197494608
Report Date: 10/23/2023
Date Signed: 10/23/2023 03:55:10 PM

Substantiated


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
10/17/2023 and conducted by Evaluator Lilia Hernandez
PUBLIC
COMPLAINT CONTROL NUMBER: 58-CC-20231017085831
FACILITY NAME:OUR LADY OF MALIBU CHURCH AND SCHOOLFACILITY NUMBER:
197494608
ADMINISTRATOR:REV MATHEW MURPHYFACILITY TYPE:
850
ADDRESS:3625 S WINTER CANYON RDTELEPHONE:
(310) 456-8071
CITY:MALIBUSTATE: CAZIP CODE:
90265
CAPACITY:22CENSUS: 7DATE:
10/23/2023
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Rich Nambu, PrincipalTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff commingle different age groups
Staff do not properly qualified
Staff are not following proper sign in/out procedures

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Lilia Hernandez conducted an unannounced complaint inspection on 10/23/2023 to investigate the above allegations. LPA arrived at the facility at 09:20 AM and met with Rich Nambu, Principal who guided LPA on tour of the facility. There were 7 children and 1 staff present upon arrival.

During the investigation LPAs took pictures and and conducted interviews with licensee, and staff #1. Children's roster was not obtained.

Per Principal, children's roster was not available.

Information provided by the reporting party indicates that staff commingle different age groups, staff are not properly qualified, and staff are not following proper sign in/out procedures.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rita Ramos
LICENSING EVALUATOR NAME: Lilia Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023
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 4
Control Number 58-CC-20231017085831
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: OUR LADY OF MALIBU CHURCH AND SCHOOL
FACILITY NUMBER: 197494608
VISIT DATE: 10/23/2023
NARRATIVE
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Per Principal, children commingle with other children during drop off and pick ups. The facility has a valet for children drop off in the morning and a drive thru pick up in the elementary yard. Principal was not able to provide sign in and sign out sheets for children.

Per Principal, staff files did not have documentation to show proof of staff qualifications.

During staff interviews, S1 confirmed that children commingle with other children during morning drop offs and afternoon pickups. Per S1, there was not sign in/out sheet and one could not be provided to LPA upon request.

Based on the investigation conducted by the LPA which includes interviews, record reviews, and other pertinent information, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

California Code of Regulations, Title 22, Division 12, Chapter 1, 101161 Limitations on Capacity is being cited on the attached LIC9099D.

California Code of Regulations, Title 22, Division 12, Chapter 1, 101216 Personnel Requirements is being cited on the attached LIC9099D.

California Code of Regulations, Title 22, Division 12, Chapter 1, 101229.1 Sign In and Sign Out is being cited on the attached LIC9099D.

The Notice of Site Visit was given and must remain posted for 30 days during the hours of operation after each site visit by a licensing representative.

Exit interview was conducted and report was reviewed with Rich Nambu, Principal.
SUPERVISORS NAME: Rita Ramos
LICENSING EVALUATOR NAME: Lilia Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 58-CC-20231017085831
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: OUR LADY OF MALIBU CHURCH AND SCHOOL
FACILITY NUMBER: 197494608
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/27/2023
Section Cited
CCR
101161(a)
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101161(a) A licensee shall not operate a child care center beyond the conditions and limitations specified on the license, including the capacity limitation.
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Per Principal, a waiver request will be submitted to the Department detailing the use of the upper yard and how drop off and pick ups will be conducted to prevent commingling. Documents will be submitted to LPA by the POC due date.
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This requirement is not met as evidenced by:
Interviews conducted and disclosures made indicating that staff have children commingle with other children who are not within the licensing capacity which poses an immediate health, safety, and personal rights to children 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.
SUPERVISORS NAME: Rita Ramos
LICENSING EVALUATOR NAME: Lilia Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 58-CC-20231017085831
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: OUR LADY OF MALIBU CHURCH AND SCHOOL
FACILITY NUMBER: 197494608
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/03/2023
Section Cited
CCR
101216
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101216 Child care center personnel shall be competent to provide the services necessary to meet the individual needs of children in care and shall at all times be employed in numbers sufficient to meet those needs...
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Per Principal, personnel file for S1 will be updated and documents missing will be obtained and a copy of the documents will be submitted to LPA by the POC due date.
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This requirement is not met as evidenced by:
Interviews conducted and disclosures made indicating that the facility does not have proof of S1 qualifications which poses a potential health, safety, and personal rights to children in care.
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Type B
11/24/2023
Section Cited
CCR
101229.1
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101229.1 Sign In and Sign Out ...the licensee shall develop, maintain, and implement a written procedure to sign the child in/out of the child care center... shall be kept for one month and shall be available at the center for review by the Department.
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Per Principal, a sign in/out sheet will be used during drop off and pick up of children in care. Written procedure will include times and signature of persons authorized to drop off and pick up children. Completed sign in and out sheets will be submitted to LPA for the dates of 10/25/23 - 11/24/23 by POC due date.
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This requirement is not met as evidenced by:
Interviews conducted and disclosures made indicating that the facility does not use a daily sign in/out sheet of the children in care which poses a potential health, safety, and personal rights to children 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.
SUPERVISORS NAME: Rita Ramos
LICENSING EVALUATOR NAME: Lilia Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4