198001060-1-14-2025-33-CC-SLII-DCX2U7-20250114164154

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198001060
Report Date: 01/14/2025
Date Signed: 01/14/2025 04:42:00 PM

Document Has Been Signed on 01/14/2025 04:42 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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME:	KIDS KLUB PASADENA		FACILITY NUMBER:	198001060
ADMINISTRATOR/ DIRECTOR:	VIVIAN LEIS-CHANG		FACILITY TYPE:	850
ADDRESS:	380 SO. RAYMOND STREET		TELEPHONE:	(626) 795-2501
CITY:	PASADENA	STATE: CA	ZIP CODE:	91105
CAPACITY: 195	TOTAL ENROLLED CHILDREN: 184	CENSUS: 147	DATE:	01/14/2025
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	03:40 PM
MET WITH:	Director Gloria Talavera		TIME VISIT/ INSPECTION COMPLETED:	05:00 PM

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Licensing Program Analyst (LPA) Stephanie Li conducted a case management inspection to follow up regarding an incident that was reported to licensing on 12/19/24 regarding in injury requiring medical attention that occurred on 12/17/24. LPA met with Director Gloria Talavera, who gave a tour of the facility. Census was taken. There were 147 children and 24 staff during the time of visit. Risk assessment was done.

The incident report stated a 3 year old child lost his balance causing him to trip and fall bumping his mouth on the ground chipping his right tooth. The impact of fall also caused lip swelling and bruising.

LPA conducted interview with Director Gloria and observed the area where the child tripped and fell. Per director, child was stepping down from the raised floor between the art easel towards the walking path. His foot caught on the raised ledge and he fell forward onto the path landing on his face. Photos were captured. Director provided LPA with the child's dental note. Mother took child to dentist to assess injured tooth. Child still has his baby teeth. Dental note indicated that he was clear to return to school without restrictions. Per director, ouch report was provided to parent to sign and they retained it in his file. Director shared photos taken of injury to LPA's cell phone.

The facility is in compliance of Title 22 regulations. Incident report was sent in properly and timely. No citations are being cited during his visit.

Exit interview was conducted with Director Gloria Talavera.

SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Stephanie Li
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2024

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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