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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198006185
Report Date: 05/29/2026
Date Signed: 05/29/2026 12:14:57 PM

Document Has Been Signed on 05/29/2026 12:14 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:COLUMBUS STATE PRESCHOOLFACILITY NUMBER:
198006185
ADMINISTRATOR/
DIRECTOR:		ACEITUNO, ALLESONFACILITY TYPE:
850
ADDRESS:425 W. MILFORD STREETTELEPHONE:
(818) 241-3111
CITY:GLENDALESTATE: CAZIP CODE:
91203
CAPACITY: 26TOTAL ENROLLED CHILDREN: 28CENSUS: 19DATE:
05/29/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Alyson Beecher, Program SupervisorTIME VISIT/
INSPECTION COMPLETED:
12:25 PM
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On 05/29/26, at 11:15 AM Licensing Program Analyst (LPA) Anomeh Eivazian conducted an unannounced case management inspection to deliver the findings due to an incident that occurred on Monday, 05/18/26. This facility is one of Glendale Unified School District sites. The program operates AM and PM in Room 1105. LPA arrived at the facility, entered through school main entrance and was guided to the preschool 1105 classroom. Upon arrival in Room 1105, LPA met with teacher Lucia Derbedrossian and waited in classroom 1105. Upon arrival, there were 19 children present in the classroom having lunch with 5 staff for AM session. Shortly after LPA’s arrival Alyson Beecher, Program Supervisor arrived to the classroom who guided analyst on a tour of the facility.

Alleged Incident took place on Monday 05/18/26, child#1 disclosed it to staff#3 on Tuesday 05/19/26, the staff#1 pulled child#1’s hair yesterday. Program Supervisor was informed about the incident next day on Wednesday 05/20/26 and reported the incident on the same day on Wednesday 05/20/26 via email. Original LIC 624 Unusual Incident/Injury Report form was received by the Department within 7 days. The facility reported the incident within the required 24-hour time frame.

LPA conducted interviews with four staff, one child and one parent on 05/22/26. LPA obtained a copy of internal investigation.

Based on four staff interviews, children only use classroom 1105 bathrooms and leave the bathroom door open all the time.


REPORT CONTINUES ON NEXT PAGE 1 OF 2
NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Anomeh Eivazian
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/29/2026
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 3
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: COLUMBUS STATE PRESCHOOL
FACILITY NUMBER: 198006185
VISIT DATE: 05/29/2026
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Based on an interview that was conducted with staff#3 and staff#4, no disclosure was made regarding this incident. Per staff#3, the only time that she can recall staff#1 be in the bathroom with child#1, was on Monday 05/19/26, when child#1 put fingers in mouth and staff#1 assisted child#1 to wash hands in the bathroom of the classroom with the door open. Per staff#3, she heard staff#1 was talking to child#1 in Armenian, but staff#3 does not understand Armenian and she did not observe what was happening in the bathroom.

Based on an interview that was conducted with child#1, child#1 stated staff#1 pulled child#1’s hair but did not mention where, why or how.

Based on an interview that was conducted with staff#2, she can recall that sometimes recently, can not recall the exact date, child#1 was on the carpet area and child#1 put fingers in mouth, at that time when all the children were on the carpet area, and staff#3 was leading the classroom and staff#4 was also present in the carpet area, staff#3 took child#1 in the boys bathroom, which is located in the classroom 1105 with the door open. Per staff#2, child#1 started to play with water and soap, and child#1 had soap and water all over on face, hands and hair. Per staff#2, she attempted to redirect child#1 to stop playing with water. Per staff#2, she wiped child#1’s hair and face with paper towel. Per staff#1, she wiped child#1’s hair gently with paper towel. Per staff#1 she was taking small portion of chid#1’s hair and wipe down the paper towel gently to clean child#1’s hair. Per staff#1, child#1 did not complaint or said anything while she was cleaning child#1’s hair and face and was calm.

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. Therefore, there are no deficiencies being cited at this time.

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, program supervisor, Alyson Beecher.


REPORT END 2 OF 2
NAME OF LICENSING PROGRAM MANAGER: Christina Gabelman
NAME OF LICENSING PROGRAM ANALYST: Anomeh Eivazian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2026
LIC809 (FAS) - (06/04)
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