<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198001060
Report Date: 01/11/2023
Date Signed: 01/11/2023 03:00:52 PM

Document Has Been Signed on 01/11/2023 03:00 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:KIDS KLUB PASADENAFACILITY NUMBER:
198001060
ADMINISTRATOR:VIVIAN LEIS-CHANGFACILITY TYPE:
850
ADDRESS:380 SO. RAYMOND STREETTELEPHONE:
(626) 795-2501
CITY:PASADENASTATE: CAZIP CODE:
91105
CAPACITY: 195TOTAL ENROLLED CHILDREN: 195CENSUS: 133DATE:
01/11/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Director, Gloria TalaverasTIME COMPLETED:
03:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Bardo Baluyot conducted a case management inspection to follow up an incident that occurred at the facility on 1/5/22. LPA conducted a COVID risk self-assessment upon entry and met with Director, Gloria Talaveras who guided LPA on a tour of the facility. The incident was reported to the Department within the required 24 hours of occurrence.

Based on all information obtained and LPA's own observation of the play structure; no follow-up is necessary regarding the incident. The facility staff could not have done anything to prevent the incident from occurring and preventative measures are being taken in order to prevent a similar incident from occurring in the future.
The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site inspection by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.

There were no deficiencies observed in regards to today's inspection.

Exit interview was conducted with Director, Gloria Talaveras. Appeal rights explained & provided.

SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Bardo Baluyot
LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2023
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 1