198001062-4-8-2024-33-CC-SSAN-D45TNW-20240408145325

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198001062
Report Date: 04/08/2024
Date Signed: 04/08/2024 02:53:31 PM

Document Has Been Signed on 04/08/2024 02:53 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:	198001062
ADMINISTRATOR/ DIRECTOR:	WOJCIECHOWSKI, MICHAEL		FACILITY TYPE:	840
ADDRESS:	380 SO. RAYMOND STREET		TELEPHONE:	(626) 795-2501
CITY:	PASADENA	STATE: CA	ZIP CODE:	91105
CAPACITY: 60	TOTAL ENROLLED CHILDREN: 42	CENSUS: 4	DATE:	04/08/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:15 PM
MET WITH:	Tabetha Turner		TIME VISIT/ INSPECTION COMPLETED:	03:15 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	On 04/08/2024 ,at 01:15 pm Licensing Program Analyst (LPA) Shushanik Safaryan conducted an unannounced annual random inspection to the above facility . A COVID-19 risk assessment was conducted prior to entering the facility. Upon arrival LPA met with Facility Representative Tabetha Turner . This is the School age program operates Monday through Friday from 7:00AM to 06:00 pm . Facility also has a preschool and infant license on the same grounds .Per Facility Representative there are 42 children enrolled. Upon arrival LPA observed all the necessary postings by the main entrance. At 12:15 pm LPA was guided to the tour of the facility. During the tour LPA observed 4 children with 2 staff members. Teacher child ratios were observed to be in accordance with Title 22 Regulations. Staff names were recorded. All children were observed to be under supervision, including visual supervision. Licensed facility is within the conditions, limitations, and capacity specified on the license. Facility consists of 3 classrooms. Classrooms furniture and equipment were inspected for good repair, free of sharp, loose, or pointed parts. Classrooms were inspected to that the floors have a surface that is safe and clean. All toilets and washing facilities are in safe and sanitary operating conditions. All materials and surfaces accessible to children are toxic free. First Aid supplies are available and complete. The facility provides lunch and pm snacks . Menus were reviewed to ensure that they are being posted at least one week in advance and visible to an authorized representative . Drinking water was available indoor and outdoor. Per Facility Representative lunch and snacks prepared and distributed from the kitchen .Kitchen was observed to be clean, and the cleaning compounds/solutions were found to be stored away from the food. All storage containers for solid waste, including moveable bins shall have tight-fitting covers that are kept on, and in good repair. Trash cans used to discard food have tight fitting lids. The facility was observed to be free of flies, other insects, and rodents. Page 1 of 3

SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Shushanik Safaryan
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2024

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 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 198001062
	VISIT DATE: 04/08/2024

NARRATIVE

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LPA observed smoke and carbon detectors in the facility. LPA observed a fully charged and serviced fire extinguisher with service tag 12/11/2023. Disaster drills shall be conducted and documented , per facility Representative last drill was conducted on 03/25/2024.

The staff office and staff restroom will be used for the ill children. There is a mat for an ill child.

School age program uses for outdoor play area Hard Yard including drive way and Wood Chip Yard which was fenced .Outdoor playground equipment is in safe condition, free of sharp, lose or pointed parts. The surface of the outdoor activity space is maintained in a safe condition and is free of hazards. All areas around or under high climbing equipment, swings, slides, and similar equipment are cushioned with rubber material that absorbs a fall. There is adequate shade in the play yard.

Sign in and out sheets were reviewed to ensure that the person who signs the child in and out uses their full legal signature and records the time of the day. Facility uses a program called Pro Care to sign children in and out. Facility has hard copies of sign in and sign out sheets as needed. Facility provides transportation.

Children’s Records were reviewed to ensure that Identification and Emergency form and a medical assessment are on file. Children’s records complete. LPA reviewed staff records; staff files were complete. Criminal Records Clearance for adults and verification of CPR/First Aid and Mandated Reporter Training's documentation was reviewed.

AB1207 Mandated Child Abuse Reporting – On or before March 30, 2018, any person who works in a childcare facility shall complete the training and renew the training every 2 years. Website provided: https://www.mandatedreporterca.com/training/child-care-providers

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice(USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

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SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Shushanik Safaryan
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 198001062
	VISIT DATE: 04/08/2024

NARRATIVE

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LPA advised the licensee to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov.

Facility Representative was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Facility Representative was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test. LPA verified that the lead testing was completed in accordance with the Written Directives outlined in PIN 21-21.1-CCP and based on the results from Water board no exceedance detected .

Based on the LPA’s observations and records reviews, no deficiencies were sited .

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

An exit interview was conducted, and a copy of the report was provided to Facility Representative Tabetha Turner along with appeal rights.

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SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Shushanik Safaryan
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2024

LIC809 (FAS) - (06/04)

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