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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198001062
Report Date: 11/05/2024
Date Signed: 11/05/2024 02:22:17 PM

Document Has Been Signed on 11/05/2024 02:22 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:
11/05/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:13 PM
MET WITH:Tabetha Turner TIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On 11/05/24 , 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 Tabetha Turner . 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 .
During the investigation , LPA interviewed S1 present during the incident . S1 stated she was only staff present in the hard yard with 10 children . Per S1 she saw C1 on his knees next to the slide of the structure. Per S1 she asked C1 who indicated everything was fine. S1 stated when C2 came up and needed help C1 came up at the same time and indicated hitting his forehead on the pole while ducking . Per S1 C1 pointed at the same area where S1 observed C1 on his knees .S1 stated C1 was attended immediately. LPA was not able to interview C1 due to irregular schedule.

Based on the information obtained , no deficiencies were cited at this time .

Exit interview conducted with the Tabetha Turner 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.

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SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Shushanik Safaryan
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2024
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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