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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198001062
Report Date: 07/18/2024
Date Signed: 07/18/2024 06:40:44 PM

Document Has Been Signed on 07/18/2024 06:40 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 PASADENAFACILITY NUMBER:
198001062
ADMINISTRATOR/
DIRECTOR:
WOJCIECHOWSKI, MICHAELFACILITY TYPE:
840
ADDRESS:380 SO. RAYMOND STREETTELEPHONE:
(626) 795-2501
CITY:PASADENASTATE: CAZIP CODE:
91105
CAPACITY: 60TOTAL ENROLLED CHILDREN: 60CENSUS: 56DATE:
07/18/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Krystal RamirezTIME VISIT/
INSPECTION COMPLETED:
10:45 AM
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On 07/18/24 ,at 08:30 am Licensing Program Analyst (LPA) Shushanik Safaryan conducted an unannounced Case Management Inspection to follow up on the incident that took place on 07/08/24. LPA met with Director Krystal Ramirez , who guided LPA on a tour of the facility. School Age Program Director Crystal Garcia came in later .

The Unusual Incident/ Injury Report was reported as required. This is the School Age program that consists of 5 groups . During the visit LPA observed 56 children with 10 staff members. LPA observed the area where alleged incident took place.( Pictures were taken). LPA conducted an interview with the School Age Program Director, staff member and child involved in the incident . Per Director first aide was provided , parents were notified. Per Director child was back to school next day . LPA obtained incident report submitted to the parents of child #1 and visit summary from the doctor. Per child #1 she found the beads outside in the play area and put it in her ear , later when she was not able to remove it, she notified staff member . During the incident 30 children were present with 4 staff members . Per Director outdoor yard gets cleaned every day .Per staff member those particular beads only used once in a months to make jewelry. Children play with the beads only in the kitchen under the staff supervision . LPA observed beads stored in the container inside of the cabinet . Per Director staff reminding children safety rules when they play with the beads .

At this time, there is not a preponderance of evidence that shows that the facility was in violation with Title 22 Regulations when this incident occurred. No citations issued at this time .
Exit interview conducted with the Director Krystal Ramirez and Copy of Report and Notice of Site visit was provided .

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.

End of the report .

SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Shushanik Safaryan
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2024
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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