198001062-4-8-2024-33-CC-SSAN-D45TQH-20240408145558

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198001062
Report Date: 04/08/2024
Date Signed: 04/08/2024 02:56:01 PM

Document Has Been Signed on 04/08/2024 02:56 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:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:45 AM
MET WITH:	Tabetha Turner		TIME VISIT/ INSPECTION COMPLETED:	01:10 PM

NARRATIVE

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Licensing Program Analyst (LPA) Shushanik Safaryan conducted an unannounced Case Management Inspection to follow up on the incidents that took place on 01/29/2024 and 03/29/2024. LPA met with Executive Director, Tabetha Turner , who guided LPA on a tour of the facility.

The Unusual Incident/ Injury Reports were reported as required. This is the School Age program. LPA observed the areas where alleged incidents took place.( Pictures were taken.) During the tour of outdoor play area LPA observed padding around the poles where one of the incidents took place .

LPA conducted an interview with 2 staff member and 1 child . Based on the interviews first aide was provided in timely manners, parents were notified, one child was back same day and the other child was back next day .During the visit LPA obtained ouch reports for both incidents .

At this time, there is not a preponderance of evidence that shows that the facility was in violation with Title 22 Regulations when these incidents occurred. Therefore, there are no deficiencies being cited.

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.

Exit interview conducted with the Executive Director Tabetha Turner and Copy of Report provided.

END OF REPORT

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)

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