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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198015952
Report Date: 08/25/2021
Date Signed: 08/25/2021 11:54:24 AM

Document Has Been Signed on 08/25/2021 11:54 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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:BETHANY MANOR DEVELOPMENT AND LEARNING CENTERFACILITY NUMBER:
198015952
ADMINISTRATOR:RENEE KOSKAFACILITY TYPE:
850
ADDRESS:15415 S. PIONEER BLVD.TELEPHONE:
(562) 868-1517
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 64TOTAL ENROLLED CHILDREN: 0CENSUS: 23DATE:
08/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Renee Koska, DirectorTIME COMPLETED:
12:20 PM
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An unannounced Required 1 Year Inspection was conducted on this day by Licensing Program Analyst (LPA) A. Lucero. Facility is currently licensed for a capacity of 64 children. Licensing staff met with Director Renee Koska who guided LPA on an indoor and outdoor tour of the facility. The program currently operates Monday, Wednesday and Friday from 9:00am to 12:00 noon.

At around 9:35am, LPA began an indoor tour of the facility. LPA observed a total census of 23 children in care. Furniture and equipment was inspected for age appropriateness and good repair. Telephone service, heating, lighting and ventilation were evaluated. Storage for children's belongings was observed. Availability of drinking water was reviewed. Age appropriate sinks and toilets were inspected for availability, good repair, water temperature, toilet paper, area safety and sanitation. Toys observed to be clean.

A first aid kit is kept in each classroom. Carbon monoxide detectors and smoke detectors are present in the facility. Fire extinguishers have been serviced in December 2020. Hazardous items including poisonous cleaning compounds were stored inaccessible to children.

The facility does not provide a snack for children as the children are only present for three hours a day, but do provide a snack time. Parents provide snacks for children, but the facility does have extra snack in the event a child's representative forgets to bring a snack. No lunch is served.

The outdoor area was inspected. The children primarily use the Gross Motor Room for play activities; however, an outdoor grassy area is utilized in the event outdoor play area is needed for 15 minutes or for outdoor painting projects. LPA Lucero advised Teacher that the children need to be within the direct care and supervision, including visual supervision of the teacher(s) at all times. Outdoor play area was inspected for hazards and inaccessibility to bodies of water; no bodies of water or hazards observed.
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Armando J Lucero
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: BETHANY MANOR DEVELOPMENT AND LEARNING CENTER
FACILITY NUMBER: 198015952
VISIT DATE: 08/25/2021
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Teacher-child ratios were observed and staff names recorded. LPA determined that staff member Johnny Cabral is not fingerprint cleared and has been employed with the facility since 08/09/2021 and was physically present in classroom with children since 08/11/2021. Director provided LPA with Request for Live Scan Service (LIC 9163) for Johnny Cabral that was taken on 08/12/2021. Due to employee Johnny Cabral not being fingerprint cleared and working in the facility, a civil penalty of $500 was assessed.

Care and supervision was evaluated to determine if the basic needs of children are met and appropriate. Sign-in and out sheets and procedures were reviewed. Personal Rights of children were observed by LPA. Staff and Children’s Records were reviewed. Criminal Record Clearances were reviewed for adults. At about 10:00am, LPA conducted file reviews. LPA determined that staff have taken CPR training with an American Red Cross Instructor; however, records provided on this date were certificates that had been printed out and do not have the American Red Cross logo. Furthermore, the certificates do not have EMSA certified Pediatric First Aid/Pediatric CPR stickers and are not American Red Cross cards.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

The following was discussed with the Director:

Rooms that are off-limits need to be made inaccessible during operating hours. Smoking is prohibited. The Director was advised that inaccessibility of hazards must be constantly reassessed depending on the children in care.

The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary. Smoke and Carbon Monoxide detectors should be checked and batteries replaced as needed. Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your location.
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Armando J Lucero
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
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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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: BETHANY MANOR DEVELOPMENT AND LEARNING CENTER
FACILITY NUMBER: 198015952
VISIT DATE: 08/25/2021
NARRATIVE
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Mandatory Forms for the children’s files and staff files, requirements for fire drills, earthquake drills and documentation were discussed. Role and responsibilities of being a Mandated Reporter were reviewed. The Director was advised how to access forms and Regulations online at www.ccld.ca.gov. Director was made aware that it is his/her responsibility to know the regulations as well as anyone who assists in providing care. The Director was advised that inaccessibility of hazards must be constantly reassessed depending on the children in care.

LPA advised Director that all adults 18 years of age and older providing Care & Supervision and/or have continuous presence in the facility shall adhere to a criminal background clearance with the Department of Justice, FBI and Child Abuse Index Check. LPA informed Director to log onto web site www.ccld.ca.gov to obtain forms and LIVE SCAN application. Records for all children and staff must be maintained for three (3) years after separation from the facility.

The Director was also advised of the requirement to report Unusual Incidents and/or injuries to the parent/guardian and to CCL within the time frame specified by the regulation. Director advised that indoor and outdoor supervision required at all times. If outdoor area not adequately fenced, provider must be with children at all times when outdoors.

See deficiencies page for deficiencies cited during today's visit in accordance to the California Code of Regulations Title 22, Division 12, Chapter 1

Upon receipt of this report, the Licensee shall post the Notice of Site Visit and any Licensing report documenting a type “A” deficiency. The report and the Notice of Site Visit shall be posted for 30 consecutive days. Failure to maintain posting as required, will result in an immediate $100 civil penalty. Exit interview, copy of report was given.
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Armando J Lucero
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
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Document Has Been Signed on 08/25/2021 11:54 AM - It Cannot Be Edited


Created By: Armando J Lucero On 08/25/2021 at 11:12 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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: BETHANY MANOR DEVELOPMENT AND LEARNING CENTER
FACILITY NUMBER: 198015952

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/25/2021
Section Cited
CCR
101170(e)(1)

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Criminal Record Clearance
All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: obtain a California clearance or a criminal record exemption as required by the Department
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Director stated that she will contact Guardian to determine why Johnny Cabral has yet to clear fingerprints. Director stated that Johnny Cabral will not be present at facility until he has cleared. Director is to submit proof of clearance to LPA via email.
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The requirement is not met as evidenced by:
staff member Johnny Cabral is not fingerprint cleared and has been employed with the facility since 08/09/21 and was physically present in classroom with children since 08/11/21. Director provided LPA with (LIC 9163) for Johnny Cabral that was taken on 08/12/21. This is a potential risk.
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Type B
09/24/2021
Section Cited
CCR101216(f)

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Personnel Requirements

At least one staff member who is trained in pediatric cardiopulmonary resuscitation and pediatric first aid pursuant to Health and Safety Code Section 1596.866 shall be present when children are at the child care center or offsite for center activities.
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Director stated that she will obtain the EMSA certified stickers from the instructor, or obtain actual American Red Cross Cards, or re-enroll in a new course to obtain the cards. Director will email LPA copy of correction by POC date of 09/24/2021.
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The requirement is not met as evidenced:
Staff have taken CPR training with an American Red Cross Instructor; however, records provided on this date were certificates that had been printed out and do not have the American Red Cross logo. Furthermore, the certificates do not have EMSA certified Pediatric First Aid/Pediatric CPR stickers and are not American Red Cross cards.
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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:Valarie Cook
LICENSING EVALUATOR NAME:Armando J Lucero
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2021


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