<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198020505
Report Date: 07/13/2022
Date Signed: 07/13/2022 11:12:58 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/04/2022 and conducted by Evaluator Nolan Tcheng
PUBLIC
COMPLAINT CONTROL NUMBER: 33-CC-20220504140404
FACILITY NAME:KIDDIE ACADEMY OF PASADENAFACILITY NUMBER:
198020505
ADMINISTRATOR:CHRISTINE JENNINGSFACILITY TYPE:
830
ADDRESS:169 HALSTEAD STTELEPHONE:
(626) 606-2800
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY:44CENSUS: 19DATE:
07/13/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Stassia House - Assistant DirectorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is operating out of ratio
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Nolan Tcheng conducted an unannounced inspection for the purpose of delivering complaint findings. Upon arrival at 10:30am, LPA was greeted by Assistant Director Stassia House, to whom the purpose of the inspection was explained. At 10:35am, LPA was given a tour of the facility where there were children present at the time of inspection.

Census was taken. There were 5 children and 3 staff for Room 1 (Infant 6weeks-10mo), 10 children and 4 staff in Room 2 (10mo-17mo), and 4 children and 2 staff in Room 4 (17mo-24mo).

During the course of the investigation Interviews were conducted with thirteen staff members. LPA obtained documentation in the form of Children sign in and out sheets, Staff Timesheets, and Written Declarations.

REPORT CONTINUES PAGE 1 of 3
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Nolan Tcheng
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 33-CC-20220504140404
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: KIDDIE ACADEMY OF PASADENA
FACILITY NUMBER: 198020505
VISIT DATE: 07/13/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Information from the complainant indicates that the facility is operating out of ratio.

Director stated their understanding of the Teacher-child ratio being 1 Teacher to 4 infants. During interview with licensing staff, director notes that there was one incident where a teacher stepped out of a room, leaving additional staff out of ratio in the classroom.

During interviews with staff, LPA received disclosures that indicate teachers and children in care are out of ratio. Corroborating statements from multiple staff support the Director’s comments made, involving a staff member who left an infant room out of ratio. Additional staff interviews provided corroborating statements, disclosing that morning is usually when they are out of ratio. Disclosures state that they could be over ratio by 1-2 children and they may not have someone to step in to help until a few minutes after. One staff interview notes that the morning of LPA’s inspection, on 06/21/2022, teachers were out of ratio in the morning before more staff arrived to assist and ensure that rooms were adhering to the Teacher-Child Ratio. Based on the statements made by staff members during interview, the facility has operated out of the Teacher-Child Ratio.

LPA discussed ratio with the director and how to ensure that it is always maintained at the facility. A plan of correction was reviewed and developed.

This agency has investigated the complaint alleging that there was a violation of Title 22, Division 12, Chapter 1, Article 6, Section 101416.5(b) "Staff-Infant Ratio.” The complaint alleged that “Facility is operating out of ratio.” Based upon the evidence as presented above, the allegation has been determined to be Substantiated. A finding of Substantiated means that the preponderance of evidence standard has been met. California Code of Regulations, Title 22, Division 12, Chapter 1, Article 06, Section 101416.5(b) "Staff-Infant Ratio.” is being cited on the attached LIC 9099D.

Please refer to 9099D for documentation of deficiencies.

Upon receipt, the Licensee shall post the “D” page of the Licensing report. This page shall be posted for 30 consecutive days. Failure to maintain posting as required will result in a $100 civil penalty. A copy of this report shall be provided to the parents/guardians of the children currently enrolled by the next business day or immediately upon return. A copy of this report shall also be provided to the parents/guardians of any children newly enrolled at the facility for the next 12 months. The LIC 9224 Acknowledgement of Receipt of Licensing Reports must be maintained in each child's file immediately upon receipt from the parent. LPA provided Licensee with a blank copy of the LIC 9224 Acknowledgement of Receipt of Licensing Report.


REPORT CONTINUES PAGE 2 of 3
SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Nolan Tcheng
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 33-CC-20220504140404
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: KIDDIE ACADEMY OF PASADENA
FACILITY NUMBER: 198020505
VISIT DATE: 07/13/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
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 Assistant Director Stassia House, at 11:20am. Copy of report was provided.



END OF REPORT PAGE 3 of 3.
SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Nolan Tcheng
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 33-CC-20220504140404
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: KIDDIE ACADEMY OF PASADENA
FACILITY NUMBER: 198020505
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/14/2022
Section Cited
CCR
101416.5(b)
1
2
3
4
5
6
7
Staff-Infant Ratio
(b)There shall be a ratio of one teacher for every four infants in attendance.




This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Per Assistant Director, the facility has hired extra staff members for each classroom since the issues have happened. Each classroom will have a sign in sheet for when teachers arrive each day that require number children, time, signature, and wtiness' signature. A form noting that all staff have been informed of the new sign in process and that all staff
8
9
10
11
12
13
14
Based on interview, Licensee did not ensure that rooms maintained the staff-infant ratio of 1:4. DIsclosures revealed that rooms have been out of ratio on different occassions. This poses an immediate risk to the health, safety, and personal rights of children in care
8
9
10
11
12
13
14
are understanding of the new sign in process for each classroom will be created, signed by all staff, and sent to LPA by POC date along with all requested documents.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Claudia Guangorena
LICENSING EVALUATOR NAME: Nolan Tcheng
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4