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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198001060
Report Date: 12/19/2024
Date Signed: 12/19/2024 03:46:00 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/29/2024 and conducted by Evaluator Shushanik Safaryan
PUBLIC
COMPLAINT CONTROL NUMBER: 33-CC-20241029153202
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:195CENSUS: 89DATE:
12/19/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Gloria Talavera TIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility staff do not keep kitchen equipment in operating condition.
Facility staff do not keep food properly stored and labeled.
Facility does not sanitize dishes and utensils.
INVESTIGATION FINDINGS:
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On 12/19/2024, at 2:00 PM , Licensing Program Analyst (LPA) Shushanik Safaryan conducted an unannounced complaint inspection to deliver the findings of complaint # 33-CC-20241029153202
Upon arrival, LPA met with Facility Representative Gloria Talavera, who was informed of the purpose of the visit. A tour of the facility was conducted, and a census was taken. There were 89 napping children present, accompanied by 10 staff members.

Allegation: Facility staff do not keep kitchen equipment in operating condition.

As part of the investigation, LPA visited the facility on 11/05/2024 and received information that the refrigerator in the kitchen was not functioning properly. According to the facility staff, the refrigerator door was not closing properly, and a sign had been placed on the door to remind staff to ensure it was closed. During the tour, LPA observed the sign on the refrigerator door. Both the Director and the staff reported that various attempts had been made to fix the door but without success.
Page 1 of 4
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Shushanik Safaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
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 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/29/2024 and conducted by Evaluator Shushanik Safaryan
PUBLIC
COMPLAINT CONTROL NUMBER: 33-CC-20241029153202

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:195CENSUS: 89DATE:
12/19/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Gloria Talavera TIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility staff are not practicing proper personal hygiene before serving food.
INVESTIGATION FINDINGS:
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On 12/19/2024, at 2:00 PM , Licensing Program Analyst (LPA) Shushanik Safaryan conducted an unannounced complaint inspection to deliver the findings of complaint # 33-CC-20241029153202
Upon arrival, LPA met with Facility Representative Gloria Talavera, who was informed of the purpose of the visit. A tour of the facility was conducted, and a census was taken. There were 89 napping children present, accompanied by 10 staff members.

During the investigation, LPA visited the facility on 11/05/24. Upon arrival, LPA observed children lining up to wash their hands before lunch. LPA also observed staff wearing gloves while serving food. Additionally, LPA noted that gloves, disposable plates, and utensils were stored in both the outdoor area and the Art room.
According to staff members, children wash their hands before lunch, and staff model proper handwashing techniques as an example to encourage the children to wash their hands correctly.
Page 1 of 2



Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Shushanik Safaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 33-CC-20241029153202
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: KIDS KLUB PASADENA
FACILITY NUMBER: 198001060
VISIT DATE: 12/19/2024
NARRATIVE
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The kitchen staff explained that prepared food is placed in bowls on a cart and then served by the classroom teacher.

LPA observed kitchen staff wearing gloves during lunch preparation. Staff members confirmed that everyone washes their hands before and after handling food, and teachers wear gloves while serving meals. No staff member was observed failing to follow proper personal hygiene practices.

Based on LPA’s observations and staff interviews, while the allegation may have been plausible, there is insufficient evidence to substantiate the claim that the alleged violations occurred. Therefore, the allegation is deemed unsubstantiated.

An exit Interview was conducted, and a copy of this report along with Notice of Site visit and Appeal Rights were explained and provided to the Facility Representative, Gloria Talavera on 12/19/2024.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.

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SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Shushanik Safaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 33-CC-20241029153202
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: KIDS KLUB PASADENA
FACILITY NUMBER: 198001060
VISIT DATE: 12/19/2024
NARRATIVE
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LPA obtained a work order from the Director indicating that the door would be repaired and that the necessary part had been ordered.

Next, LPA toured the storage room and observed three freezers and one refrigerator. During this inspection, LPA noted that one of the freezers was being used as a refrigerator. According to the Director, the facility has two other freezers in use and does not require an additional one. Staff explained that the refrigerator could not maintain a freezer temperature and had been re-purposed as a regular refrigerator.

Allegation: Facility does not sanitize dishes and utensils.

During the investigation, LPA visited the facility on 11/05/24. During the visit, LPA interviewed six staff members, from whom information was gathered that the facility's dishwasher was broken and had never been replaced. According to two staff members, dishes are washed with hot water and soap, but sanitization is not performed. The Director stated that sanitizer was available in the kitchen; however, staff reported that the sanitizer dispenser was not functioning properly and could not dispense sanitizer. LPA observed that sanitizer was available in the kitchen but noted that it was not being used during dishwashing.

Allegation: Facility staff do not keep food properly stored and labeled.

During the investigation, LPA visited the facility on 11/05/24. During the kitchen tour, LPA inspected the refrigerator and made the following observations:

• On the bottom shelf of the refrigerator, LPA noticed a white plastic bag (photos were taken). The Director opened the bag, revealing two plastic containers with holes in the lids. Upon inspection, LPA observed worms inside the containers. The Director confirmed that the containers held animal food.

• Adjacent to the plastic bag, LPA observed various vegetables in an open plastic container. The Director indicated that these vegetables were for a science project; however, LPA did not observe any signage to indicate this. On the same shelf, LPA saw a gallon of milk and a container of lemon juice.

Page 2 of 4
SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Shushanik Safaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 33-CC-20241029153202
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: KIDS KLUB PASADENA
FACILITY NUMBER: 198001060
VISIT DATE: 12/19/2024
NARRATIVE
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• On the top shelf of the refrigerator, LPA observed paper cups covered with plastic, which staff identified as leftovers.

Next, LPA inspected the freezer in the kitchen and made the following observations:

• On the top shelf, LPA observed cubes of blood worms used for feeding animals. Some blister packs were partially used and stored in an open foam box. Beneath the blood worms, LPA found frozen waffles removed from their packaging and an open box of popsicles. Beneath the waffles, LPA noted food stored in a foil covered container, which staff indicated was prepared food for lunches.

• Adjacent to the blood worms, LPA observed two blue containers labeled "Animal Food Only, Do Not Remove." On the same shelf, LPA saw a box of vanilla ice cream and a bag of frozen vegetables.

• On the bottom shelf, LPA observed a plastic container with no lid, only covered with plastic wrap. Staff explained that this contained chicken stock, labeled with a date of 07/19. Above the chicken stock, LPA found a tomato sauce container and a package of frozen dough wrapped in plastic, without a package or label.

During interviews, staff confirmed that animal food was always stored in the refrigerator and freezer in the kitchen. One staff member stated that animal food should be stored on the top shelf of the freezer and the bottom shelf of the refrigerator. However, LPA did not observe any labels indicating proper food storage within the refrigerator or freezer.

During the kitchen tour, LPA also observed a small cabinet where dry animal food was stored. In an interview, the Director discussed the importance of labeling food and the plan to move the animal food to a separate storage area.

Based on LPA observations, interviews conducted, and record review(s), the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

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SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Shushanik Safaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 33-CC-20241029153202
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: KIDS KLUB PASADENA
FACILITY NUMBER: 198001060
VISIT DATE: 12/19/2024
NARRATIVE
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An exit Interview was conducted, and a copy of this report along with Notice of Site visit, Deficiency pages, and Appeal Rights were explained and provided to the Facility Representative, Gloria Talavera on 12/19/2024.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.

Page 4 of 4
SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Shushanik Safaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 33-CC-20241029153202
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: KIDS KLUB PASADENA
FACILITY NUMBER: 198001060
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/26/2024
Section Cited
CCR
101227(a)(15)
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101227(a)(15) Food Services
(a) In childcare centers providing meals to children, the following shall apply: (15) All foods or beverages ... that can cause food infections or food intoxications shall be stored in covered containers at 45 degrees F (7.2 degrees C) or less. This requirement is not met evidenced by:
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Director stated animal food will be removed to a different location and it wont be stored with the food in the kitchen . Director will submit the plan of correction to the LPA by POC date , where she will indicate where animal food will be stored and how it will be inaccessible to the children.
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LPA observed blood worm cubes in the blister packs used for animals stored on the same shelf with vanilla ice cream and on the top of the frozen waffles without original box .LPA observed containers with worms with the holes on the lid in the plastic bag stored next to the vegetables, milk, and lemon juice. LPA observed open container without a lid. LPA observed paper cups covered with plastic wrap.

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Director stated facility will have refrigerator storage chart to organize food stored.Director stated kitchen staff will be reminded to label and keep food in closed containers.
Type B
12/26/2024
Section Cited
CCR
101227(a)(21)(B)
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101227(a)(21)(B) Food Services
(a) In childcare centers .. the following shall apply:(21) All dishes and utensils used..., and in the preparation of food and drink, shall be...sanitized after each use. (B) Centers not using dishwashing machines shall clean and sanitize...by an alternative comparable method. This requirement was not met evidenced by:
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Director stated facility will use alternative comparable method and will send plan of correction to LPA by POC date .
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Facility did not have a dishwasher and did not sanitize dishes using alternative comparable method. Per staff
members, dispenser for sanitizing was not working and dishes were not sanitized.

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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: Brandi VanOosten
LICENSING EVALUATOR NAME: Shushanik Safaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7