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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198014168
Report Date: 11/04/2021
Date Signed: 11/04/2021 12:58:35 PM

Document Has Been Signed on 11/04/2021 12:58 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:KIDS KLUB SAN GABRIEL / ROSEMEADFACILITY NUMBER:
198014168
ADMINISTRATOR:MARY PERALTAFACILITY TYPE:
850
ADDRESS:4930 EARLE AVENUETELEPHONE:
(626) 288-4400
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY: 149TOTAL ENROLLED CHILDREN: 149CENSUS: 20DATE:
11/04/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Maria Rennard, DirectorTIME COMPLETED:
01:00 PM
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An unannounced Case Management visit was conducted on this date by Licensing Program Analyst (LPA) Bardo Baluyot following an incident reported to CCLD on 10/25/21. LPA conducted a COVID risk assessment prior to entry and temperature was taken by reception staff. Upon arrival, LPA was greeted by Director, Maria Rennard.

Census: There were 20 pre-schoolers present in Room 6/Polar Bears. Staff-child ratio was met.

During today's inspection, Director guided the LPA on a tour of the classroom the incident allegedly occurred as well as the outdoor areas as the class was having lunch. Interviews were conducted with the Director, staff and children from that classroom. Teacher, Ms. Judy V. who was allegedly involved in the incident was not present today but LPA will conduct a phone interview at a later date. Per Director, Ms. Judy will return to work tomorrow and would be available for the interview. LPA also obtained a current roster.

No deficiencies cited today and the facility is in compliance with Title 22. Upon receipt, Director Maria Rennard posted the Notice of Site Visit. The Notice of Site Visit shall be posted for thirty (30) consecutive days. Failure to maintain posting as required will result in a $100 civil penalty.

An exit interview has been conducted with, and a copy of this report has been signed by and provided to Director, Maria Rennard. Appeal Rights have been provided and explained to Director .
SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Bardo Baluyot
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2021
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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