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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198008932
Report Date: 08/06/2021
Date Signed: 08/06/2021 12:57:03 PM

Document Has Been Signed on 08/06/2021 12:57 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:KIDZONE PRE-SCHOOL & CHILDREN CENTERFACILITY NUMBER:
198008932
ADMINISTRATOR:BOOKER, LENOREFACILITY TYPE:
850
ADDRESS:1247 W. SAN BERNARDINO RD.TELEPHONE:
(626) 967-1223
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY: 39TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
08/06/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Narissa GrovesTIME COMPLETED:
01:00 PM
NARRATIVE
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On 08/06/21 Licensing Program Analyst (LPA) Fabiola Vasquez conducted a Case Management visit. LPA met with Director, Narissa Groves. The purpose of this report is to address concerns regarding Reporting Requirements.

On 05/25/21, during an interview with Director Narissa Groves, by her own submission stated that there were three cases of head lice in the facility of children in care and was not reported to the Department. The Department does not have a record of a phone call to report the unusual incident that occurred on 05/13/21 or a written report from the Director. The unusual incident was not reported to CCLD as required. All unusual incidents must be reported timely to CCLD; with 24 hours by phone as well as in writing within 7 days. A blank copy of the Unusual Incident/Injury Report (LIC624B) was provided and completed at the time of the visit.

The deficiencies listed on the following page are being cited in accordance with California Code of Regulations Title 22. Please see attached LIC 809d.

Deficiencies that are being cited need to be cleared to protect the health and safety of children in care.

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. Failure to maintain posting as required will result in a civil penalty of $100.00.

Exit interview was conducted with Director, Narissa Groves. Appeal rights explained. A copy of the Appeal Rights and the report was provided.
SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Fabiola Vasquez
LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2021
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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Document Has Been Signed on 08/06/2021 12:57 PM - It Cannot Be Edited


Created By: Fabiola Vasquez On 08/06/2021 at 11:39 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: KIDZONE PRE-SCHOOL & CHILDREN CENTER
FACILITY NUMBER: 198008932

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/13/2021
Section Cited
CCR
101212(d)(1)(c)

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101212 Reporting Requirements
Upon the occurrence, during the operation of the child care center of any of the events specified *** a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours.**a written report** shall be submitted to the Department within seven days following the occurrence of such event. (C)Any unusual incident ***that threatens the physical or emotional health or safety of any child.

This requirement was not met as evidenced by
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Per Director, she will submit a written plan on reporting unusual incidents to LPA by due date. Licensee completed the LIC 624B Unusual Incident/Injury report during today's visit
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On 05/25/21, during an interview with Director Narissa Groves, by her own submission stated that there were three cases of head lice in the facility of children in care and was not reported to the Department.

This poses a potential risk to the health and safety of 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:Claudia Guangorena
LICENSING EVALUATOR NAME:Fabiola Vasquez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2021


LIC809 (FAS) - (06/04)
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