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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198007099
Report Date: 04/22/2025
Date Signed: 04/22/2025 11:56:12 AM

Document Has Been Signed on 04/22/2025 11:56 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:OPTIONS - WILLOWOODFACILITY NUMBER:
198007099
ADMINISTRATOR/
DIRECTOR:		DENISE MCCULLOUGHFACILITY TYPE:
850
ADDRESS:2021 ALWOOD STREETTELEPHONE:
(626) 858-0527
CITY:WEST COVINASTATE: CAZIP CODE:
91790
CAPACITY: 48TOTAL ENROLLED CHILDREN: 48CENSUS: 28DATE:
04/22/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Linda Dagne - Education SupervisorTIME VISIT/
INSPECTION COMPLETED:
12:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Nolan Tcheng conducted an unannounced Case Management inspection to follow up on an incident report submitted to the Department on 04/08/2025. Upon arrival at 8:45am, LPA met with Senior Teacher Jennifer Calvillo, to whom the purpose of the inspection was explained. Education Supervisor Linda Dagne arrived soon after. A tour of the facility was provided. There were children present during the tour.

Census was taken. There were 28 children with 10 staff members.

On 04/07/2025, around 4:20pm, a child was observed running out of the play yard gate off of Willow Ave. to their family member, who was approaching to pick up the child. Family member brought the child back to the gate where Staff #1 met them. During today's inspection, interviews were conducted with two staff members. documentation in the form of Staff written statements and reports from Fire Department were obtained.

During interview with Staff, it was explained that Staff #3 was by the swings with their back facing the gate. Staff #1 was by Willowood 2 portable, near the tree, walking towards the swing area. Per Staff #1, they observed Child #1 running towards the gate area. As they approached the gate area, the child had already exited the gate to their family member on the sidewalk. Staff #2 was already clocked out of work and observed the gate close while in their car, they then saw Child #1 with their family member walking back to the gate where Staff #1 met them. Staff #2 corroborated the positioning of Staff #1 and Staff #3. During review of the written statements, Staff recollection of events corroborated that the child was able to access the gate with any physical intervention. Staff #3 statement says that Staff #1 was calling out to Child #1 as they were running towards the gate, but child still exited. Per Education Supervisor, the West Covina Fire Department informed the facility during an inspection on 10/31/2024, that they would have to remove unapproved locks/latches on the exit doors. The play yard gate opens directly to street of Willow Ave and is dangerous for any child to access on their own. REPORT CONTINUES PAGE 1 of 2

NAME OF LICENSING PROGRAM MANAGER: Ana Chico
NAME OF LICENSING PROGRAM ANALYST: Nolan Tcheng
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2025
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
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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: OPTIONS - WILLOWOOD
FACILITY NUMBER: 198007099
VISIT DATE: 04/22/2025
NARRATIVE
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Based on the obtained information from interviews and records review, it was determined that the incident of a child being able to exit the play yard on their own due to lack of safety measures at exit doors, is a violation of Personal Rights. The incident was submitted to the department within the required 24hr period.

LPA Tcheng informed Education Supervisor that this report dated 04/22/2024 documents one Type A citation, which shall be posted for 30 consecutive days as there is immediate risk to the health, safety, and personal rights of children in care.

Also, LPA Tcheng informed the Director to provide a copy of this licensing report dated 04/22/2024, that documents any Type A citation, to parent/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC9224), or other written statement, must be placed in the child's file for verification.

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

Exit interview conducted and report was reviewed with Education Supervisor Linda Dagne, at 11:50am. Plan of corrections developed and copy of Report provided.

END OF REPORT PAGE 2 of 2

NAME OF LICENSING PROGRAM MANAGER: Ana Chico
NAME OF LICENSING PROGRAM ANALYST: Nolan Tcheng
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/22/2025 11:56 AM - It Cannot Be Edited


Created By: Nolan Tcheng On 04/22/2025 at 10:54 AM
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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: OPTIONS - WILLOWOOD
FACILITY NUMBER: 198007099

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/23/2025
Section Cited
CCR
101223(a)(2)

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101223 Personal Rights
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his her needs.

The requirement was not met as evidenced by:
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Per Education Supervisor, they will create a plan for staff stationing during outdoor play time. They will also have a bell or alarm added to the exit gates as a means of audible notification. WIll be submitted to LPA by POC date.
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Based on interview and record review, licensee did not ensure that the play yard gates provided appropriate safety mechanism to prevent Child #1 from eloping the facility grounds. This was an immediate risk to the health, safety, and personal rights of child in care.
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Plan of supervision for outdoor play will be submitted 04/23/2025. Education Supervisor contacted Facility Supervisor Andrea Butler who stated they will contact West Covina fire department for clarification on what can be provided on the doors by POC date

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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.
Ana Chico
NAME OF LICENSING PROGRAM MANAGER:
Nolan Tcheng
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2025


LIC809 (FAS) - (06/04)
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