198006185-1-27-2025-33-CC-SSAN-DDBQMX-20250127111817

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198006185
Report Date: 01/27/2025
Date Signed: 01/27/2025 11:18:26 AM

Document Has Been Signed on 01/27/2025 11:18 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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME:	COLUMBUS STATE PRESCHOOL		FACILITY NUMBER:	198006185
ADMINISTRATOR/ DIRECTOR:	ANA MENA		FACILITY TYPE:	850
ADDRESS:	425 W. MILFORD STREET		TELEPHONE:	(818) 241-3111
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91203
CAPACITY: 26	TOTAL ENROLLED CHILDREN: 26	CENSUS: 17	DATE:	01/27/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:35 AM
MET WITH:	Perla Leyva		TIME VISIT/ INSPECTION COMPLETED:	11:30 AM

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On 01/27/25, at 09:30 am ,Licensing Program Analyst (LPA) Shushanik Safaryan conducted an unannounced annual random inspection. LPA arrived at the school office and was guided to the preschool classroom. At 09:30 am LPA met with teacher Lucia Derbedrosian, who notified Site Supervisor about the visit. At 10:00 am , LPA met with the Head Teacher Alleson Aceituno-Rivera, who guided LPA on tour of the facility. Program Supervisor Perla Leyvas came in later .This facility is located on Columbus Elementary School property. This facility is one of Glendale Unified School District sites. The program operates AM and PM. AM program operates Monday- Friday 8:30 AM to 11:30 AM, and The PM program operates Monday - Friday 12:30 PM to 3:30 PM. Per Facility Representative there are 22 children enrolled.

LPA observed all required forms/publications posted in the classroom visible to the parents .
Upon arrival , LPA observed 17 children with 3 staff members .Teacher-child ratios were observed to be in accordance with Title 22 Regulations. Staff names were recorded. Licensed facility is within the conditions, limitations, and capacity specified on the license.

The classroom furniture and equipment were inspected for good repair, free of sharp, loose, or pointed parts. All classrooms were inspected to ensure that the floors have a surface that is safe and clean. All materials and surfaces accessible to children are toxic free. All toilets and washing facilities are in safe and sanitary operating conditions.

First Aid supplies are available and complete in the classroom . Per Facility Representative , children do not take nap in this program. Storage for children's belongings was inspected.

LPA observed that there are functioning smoke and carbon detectors in the facility. LPA observed a fully charged and serviced fire extinguisher with the service date 11/2024. Emergency disaster drill was last conducted on 12/13/2024. Facility Representative states there are no weapons, firearms, or bodies of water on the premises. Page 1 of 4

SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Shushanik Safaryan
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025

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 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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: COLUMBUS STATE PRESCHOOL	FACILITY NUMBER: 198006185
	VISIT DATE: 01/27/2025

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Snack menus are posted one week in advance where it is visible by the child's authorized representative. Menus for the past 30 days are available upon request. The facility provides lunch for both of the programs .Lunch is provided from school cafeteria. Teachers bring lunches from cafeteria and children eat in the classroom . Trash cans used to discard food have tight fitting lids. Drinking water is readily available both indoors and outdoors. The facility was observed to be free of flies, other insects, and rodents.

The extra room located in the classroom will be isolation area for the ill children .Cot will be available upon request. During the tour LPA observed door from the classroom that led to the Milford st. . Per Facility Representative parents pick up from Milford St side .

LPA discussed with the Program Supervisor putting door alarm or bell on the door for additional safety.

Program utilizes TK and Kindergarten play yard for outdoor activity. Waiver on file. LPA observed outdoor play area gated and separated from the older children`s play area. Outdoor playground equipment is in safe condition, free of sharp, loose, or pointed parts. The surface of the outdoor activity space is maintained in a safe condition and is free of hazards. All areas around or under high climbing equipment, slides, and similar equipment are cushioned with material that absorbs a fall. There is adequate shade in the play yard.

Sign in and out sheets were reviewed to ensure that the person who signs the child in and out uses their full legal signature and records the time of the day. Facility uses a program called Easy child truck program to sign children in and out. Facility has hard copies of sign in and sign out sheets as needed.

Children’s Records were reviewed to ensure that Identification and Emergency form and a medical assessment are on file. Inspection of required forms was made and documented on the LIC 857.

LPA reviewed staff records; staff files were complete. Criminal Records Clearance for adults and verification of CPR/First Aid and health preventative practices documentation was reviewed.

There is at least one person trained in CPR and Pediatric First Aid present during this inspection. The review of Staff records was documented on the LIC 859. Page 2 of 4

SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Shushanik Safaryan
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025

LIC809 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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: COLUMBUS STATE PRESCHOOL	FACILITY NUMBER: 198006185
	VISIT DATE: 01/27/2025

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Staff present had proof of the AB 1207 Mandated Reporter Training certificate on file.AB1207 Mandated Child Abuse Reporting – On or before March 30, 2018, any person who works in a childcare facility shall complete the training and renew the training every 2 years. Website provided: https://www.mandatedreporterca.com/training/child-care-providers.

Per Facility Representative no one enrolled need IMS services .Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice(USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

LPA advised the licensee to access forms, regulations, and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov.

Facility Representative was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Facility Representative was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

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SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Shushanik Safaryan
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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: COLUMBUS STATE PRESCHOOL	FACILITY NUMBER: 198006185
	VISIT DATE: 01/27/2025

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Based on the LPA`s observations and record review the licensee is in compliance with California Title 22 Regulations. Therefore, there are no citations being issued today.

A notice of site visit was given and must remain posted for 30 days.

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 and report was reviewed with facility representative Perla Leyvas on 01/27/2025.

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SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Shushanik Safaryan
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025

LIC809 (FAS) - (06/04)

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