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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198001061
Report Date: 06/02/2022
Date Signed: 06/02/2022 05:54:46 PM

Document Has Been Signed on 06/02/2022 05:54 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:
198001061
ADMINISTRATOR:VIVIAN CHANGFACILITY TYPE:
830
ADDRESS:380 SO. RAYMOND STREETTELEPHONE:
(626) 795-2501
CITY:PASADENASTATE: CAZIP CODE:
91105
CAPACITY: 55TOTAL ENROLLED CHILDREN: 55CENSUS: 39DATE:
06/02/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Tabetha Turner, DirectorTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Fabiola Vasquez conducted an unannounced case management inspection due to an incident that occurred on 04/23/22. LPA met with Tabetha Turner, Director at approximately 01:40 PM who guided LPA on a tour of the facility.

Piglet classroom: 11 infants with 4 adults, Kangaroo A room: 10 infants with 2 adults, Kangaroo B room: 7 infants with 2 adults, Pooh-Bears/ Bumble Bees rooms: 11 infants with 3 adults.

There were a total of 39 infants and 11 staff present upon arrival.

The incident that occurred on 04/23/22, was reported to the Department on 04/25/22, via email. The facility reported the incident in a timely manner.

LPA conducted an interview with Staff # 1, Director and obtained a copy of; First aid, sign in sheet for 4/23/22, Children Roster during this visit. LPA also visually observed the space where the incident occurred.

On 04/23/22 at approximately 5:15 PM while transitioning from the infant/toddler yard to inside infant attempted to run from his teacher causing him to lose his balance bumping his top lip on a wooden log stump. This caused a 1/3 inch long cut above his upper lip. The injury required medical attention leading for the cut to be glued together.

Based on all information obtained on this date, no follow-up is necessary regarding the incident. There was adult supervision, the incident appears to be an unusual accident. It appears to be nothing the facility staff could have done to prevent the incident from occurring.

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 $100.00.
Exit interview was conducted with Tabetha Turner, Appeal rights explained & provided.
SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Fabiola Vasquez
LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2022
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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