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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198017956
Report Date: 12/13/2021
Date Signed: 12/13/2021 03:50:52 PM

Document Has Been Signed on 12/13/2021 03:50 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:CHILDREN'S CENTER AT CALTECHFACILITY NUMBER:
198017956
ADMINISTRATOR:SUSAN WOODFACILITY TYPE:
850
ADDRESS:1200 E. CALIFORNIA BLVDTELEPHONE:
(626) 395-6860
CITY:PASADENASTATE: CAZIP CODE:
91125
CAPACITY: 108TOTAL ENROLLED CHILDREN: 108CENSUS: 89DATE:
12/13/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Susan WoodTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Crystal Green conducted an unannounced case management inspection to follow up on an incident that was reported to the Department. Due to COVID- 19 precautionary measures were taken, individuals present during inspection wore appropriate personal protective equipment. Licensing staff met with Susan Wood, Director, also present during this inspection was Alexandra Landayan, Office Manager. Census was taken.

On 11/16/2021, an unusual incident report was made to the department regarding an incident that occurred on that day involving an injured child who required medical attention. The facility reported this incident to the Department within the required 24 hours. Facility staff provided medical treatment and notified parents of incident. LPA conducted interview with one of the staff members who observed incident during this inspection. LPA determined there was adequate supervision provided the day of the incident. Based on the information obtained, there is not enough preponderance of evidence to substantiate lack of supervision.

On 12/06/2021, an unusual incident report was made to the department regarding an incident that occurred on 12/03/2021 which involved a child who became injured and required medical attention. The facility reported this incident to the Department within the required 24 hours. Facility staff provided medical treatment and notified parents of incident. LPA obtained additional information regarding the incident during this inspection. LPA determined there was adequate supervision provided the day of the incident. Based on the information obtained, there is not enough preponderance of evidence to substantiate lack of supervision. Per California Code of Regulations Title 22, Division 12, no deficiency cited during today's visit.

Exit interview conducted with the Director, Susan Wood. 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.
SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Crystal Green
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2021
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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