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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198005306
Report Date: 12/18/2024
Date Signed: 07/09/2025 09:37:19 AM

Document Has Been Signed on 07/09/2025 09:37 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:HOLY NAME OF MARY SCHOOLFACILITY NUMBER:
198005306
ADMINISTRATOR/
DIRECTOR:		ELVIA MONTANEZFACILITY TYPE:
850
ADDRESS:124 S. SAN DIMAS CANYON ROADTELEPHONE:
(909) 542-0449
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY: 40TOTAL ENROLLED CHILDREN: 40CENSUS: 28DATE:
12/18/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Elvia Montanez, DirectorTIME VISIT/
INSPECTION COMPLETED:
01:20 PM
NARRATIVE
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**This is an Amended report created by Licensing Program Analyst (LPA) Monique Ayala**

On December 18, 2024, Licensing Program Analysts (LPAs) Monique Ayala and Mariah Aguirre conducted an unannounced Case Management inspection for the above facility. LPAs met with director, Elvia Montanez who guided LPAs on a tour of the facility. LPAs observed 28 children in care.

The purpose of the inspection is to follow up on an incident that occurred on 12/11/2024 and was reported to the department on 12/12/2024; the incident was reported to the department in a timely manner.

During the inspection LPAs interviewed Staff #1 (S1) to Staff #3 (S3), interviewed Child #1 (C1), interviewed Parent #1 (P1) obtained a copy of the cookie ingredients, obtained a copy of C1's Incidental Medical Services Plan and obtained a copy of the facility's current children facility roster.

Interviews conducted disclosed that C1 was given a cookie that contained ingredients that C1 is allergic to. Per S1-S3 there was no communication with the parents that organized the event to indicated children with food allergies. Per S1-S3 they were aware of C1's allergies at the time of enrollment. Per S1, S2 and C1, the cookies were placed on the table when children arrived into the hall. Per S1 she observed a bite in C1's cookie and informed S2. S1 stated S3 was walking into the hall and verbally told S3 about C1 eating the cookie. Per S1-S3 there was no Epi-Pen for C1 on campus as P1 of C1 did not provide an Epi-Pen to the facility prior to enrollment. Per P1 an Epi-Pen was not provided to the facility this school year. S3 stated she called P1 to inform P1 that C1 had eaten a cookie that may contain items C1 is allergic to. P1 came for C1 and C1 was taken to the emergency room. Per S3, C1 did not have an allergic reaction at the facility but did have an allergic reaction at the hospital. P1 stated that the allergic reaction started in the car ride to the hospital and had progressed once at the hospital. C1 has returned to the facility and is currently still attending and enrolled.
NAME OF LICENSING PROGRAM MANAGER: Ana Chico
NAME OF LICENSING PROGRAM ANALYST: Monique Jessica Ayala
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/09/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: HOLY NAME OF MARY SCHOOL
FACILITY NUMBER: 198005306
VISIT DATE: 12/18/2024
NARRATIVE
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**This is an Amended report created by Licensing Program Analyst (LPA) Monique Ayala**

Based on interviews conducted, the facility was aware of C1's allergies and did not have communication with the parents that organized the event to indicate children with allergies. Per S1-S3, the facility was previously aware of C1 allergies. Per S1-S3, C1 did not have an Epi-Pen at the facility to ensure there is no delay in providing medical treatment for C1.

An exit interview was conducted and a copy of this report was provided to director, Elvia Montanez along with Appeal Rights. 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.
NAME OF LICENSING PROGRAM MANAGER: Ana Chico
NAME OF LICENSING PROGRAM ANALYST: Monique Jessica Ayala
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/09/2025 09:38 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 07/08/2025 01:28 PM


Created By: Monique Jessica Ayala On 12/18/2024 at 12:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: HOLY NAME OF MARY SCHOOL
FACILITY NUMBER: 198005306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
12/18/2024
Section Cited
CCR
101226(c)

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Health-Related Services: The licensee shall obtain emergency medical treatment ... or if the nature of the child's illness or injury is such that there should be no delay in getting medical treatment for the child. This requirement was not met as evidence by: Based on interviews conducted and records review,
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The director has obtained the required medication for C1 from P1.
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C1 was given a cookie that contains ingrediants C1 is allergic to. Per S1-S3 they were all aware of the allergies prior to the Christmas event. Per S1-S3 and P1 there was no Epi-Pen for C1 at the facility. This poses an immeidate health and safety risk to children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Ana Chico
LICENSING EVALUATOR NAME:Monique Jessica Ayala
LICENSING EVALUATOR SIGNATURE:
DATE: 07/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2025


LIC809 (FAS) - (06/04)
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