<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198001062
Report Date: 10/03/2024
Date Signed: 10/03/2024 03:35:11 PM

Document Has Been Signed on 10/03/2024 03:35 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: 0DATE:
10/03/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Gloria Talavera TIME VISIT/
INSPECTION COMPLETED:
04:00 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 10/03/24 , at 1:30 PM, Licensing Program Analyst (LPA) Shushanik Safaryan conducted an unannounced Case Management Inspection to follow up on the incident that took place on 09/28/24. LPA met with Gloria Talavera, Kids Klub Center Director and Debbie Rudman, Kids Klub Executive Director . Tour of the facility was provided . No children were present during the tour .

On 09/28/24 an unusual incident report was submitted to the Department regarding child sustaining an injury on the facility grounds .The Unusual Incident/ Injury Report was reported as required. LPA observed the area where alleged incident took place.( Pictures were taken).

During the inspection LPA was not able to interview staff and children present during the incident .

Due to insufficient information available at this time the above incident needs further investigation.

Exit interview conducted with the Debbie Rudman 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.




SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Shushanik Safaryan
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2024
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 1