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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198001060
Report Date: 04/13/2023
Date Signed: 04/13/2023 04:08:25 PM

Document Has Been Signed on 04/13/2023 04:08 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
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: 146DATE:
04/13/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Gloria Talavera, DirectorTIME COMPLETED:
04:10 PM
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On April 13, 2023, Licensing Program Analyst (LPA) Monique Ayala conducted an unannounced case management inspection for an incident that was reported to the department on 04/12/2023; the incident was reported timely. A COVID-19 risk assessment was conducted prior to entering the facility. LPA met with Gloria Tavalvera who guided LPA on a tour of the facility. LPA also spoke with Regional Director Vivian Chang. LPA observed 146 children in care. The facility also has a school age program, license number 198001062 and an infant program, license number 198001061.

Brief Summary: On 04/12/2023 at approximately 12:22pm Child #1 (C1) was laying his body down onto his nap mat and accidentally hit his head on the small tray of the whiteboard located in the class. As a result of hitting his head, C1 obtained a small cut approximately 1/2 an inch in length on the top right side of his head (back upper right side). Staff #1 (S1), applied light pressure to the wound to minimize the bleeding. Director assisted with cleaning the wound with soap and water. Director and S1 called parent #1 (P1) and parent #2 (P2) to notify them of the incident. P1 immediately came to pick up C1. C1 was taken to the emergency room where 2 staples were applied to close the wound.

During the inspection, LPA viewed the area where C1 was injured, obtained photos of whiteboard try, interviewed S1, staff #2 (S2) and director, LPA reviewed children and staff files. LPA was unable to interview C1 due to him being absent from the facility. Interviews with S1, S2 and director indicated that C1 was observed when the incident occurred and the classroom was in ratio. S1, S2 and director stated that there were 10 children and 2 staff at the time of the incident. LPA attempted to interview P1 and P2, but there was no answer, LPA left a voicemail with call back number.

Based on interviews conducted the incident was an accident that occurred fast and was unable to be prevented. S2 witnessed the incident. There will be no deficiencies cited today, 04/13/2023.

Per director, the facility will refrain from children laying their heads near the whiteboard tray.

An exit interview was conducted and a copy of this report was provided to director along with Notice of Site Visit.
SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Monique Jessica Ayala
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2023
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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