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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198014170
Report Date: 12/07/2022
Date Signed: 12/07/2022 04:19:57 PM

Document Has Been Signed on 12/07/2022 04:19 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:
198014170
ADMINISTRATOR:MARY PERALTAFACILITY TYPE:
830
ADDRESS:4930 EARLE AVENUETELEPHONE:
(626) 288-4400
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY: 19TOTAL ENROLLED CHILDREN: 19CENSUS: 8DATE:
12/07/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Maria Rennard - DirectorTIME COMPLETED:
04:30 PM
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Licensing Program Analysts (LPAs) Nolan Tcheng and Veronica Martinez-Garza conducted an unannounced Case Management inspection to follow up COVID-19 incident reports submitted the Department from the facility. LPAs were greeted by Director Maria Rennard, who provided LPAs with a tour of the facility

Census was taken. There were 8 children present with 7 staff members.

On 10/18/2022, the Department was notified by the California Department of Public Health (CDPH) of Los Angeles County, of a COVID-19 outbreak that was being followed up on by their Department. Per CDPH, there was three cases that appeared in a 14-day period. The persons who were positive, received their results starting from 10/03/2022 to 10/12/2022. During the inspection, LPAs interviewed one staff regarding COVID Positive reporting requirements for the facility. LPAs obtained hardcopies of incident reports and supportive documentation from CDPH. LPAs reviewed facility emails with Director sent on 10/12/2022 and determined that the wrong file was attached in the email meant for reporting of Staff #4. Copy of email was obtained. The incident report attached was a duplicate from a report submitted the week prior. The duplicate report was for a staff member a part of the preschool license component of the facility. The notification letter attached with the duplicate incident report was labeled and notified Infant families and classes, as observed by licensing staff. LPAs observed that facility followed through with correct reporting procedures with the Department of Public Health and Department of Social Services. LPAs discussed the importance of ensuring the correct report is attached to the email submitted to the Department for future cases.

LPAs observed facility to be operating with proper COVID-19 Health and Safety protocols. LPAs determined that there was not a violation of California Title 22 Regulations. No deficiencies cited during today's inspection.


The Notice of Site Visit (LIC 9213)must remain posted for 30 days during the hours of operation after each site visit made by a licensing representative.
Exit interview was conducted with Director Maria Rennard, at 4:15pm, copy of report provided.
END OF REPORT
SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Nolan Tcheng
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2022
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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