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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198020812
Report Date: 10/25/2024
Date Signed: 10/25/2024 11:44:01 AM

Document Has Been Signed on 10/25/2024 11:44 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:PASSONS ACADEMYFACILITY NUMBER:
198020812
ADMINISTRATOR/
DIRECTOR:		GOMEZ, LETICIAFACILITY TYPE:
850
ADDRESS:8415 S. PASSSONS BLVD.TELEPHONE:
(562) 231-4373
CITY:PICO RIVERASTATE: CAZIP CODE:
90660
CAPACITY: 28TOTAL ENROLLED CHILDREN: 28CENSUS: 14DATE:
10/25/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Elizabeth Ramirez, Administrator TIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Roxana Lopez conducted a Case Management-Deficiencies visit to address deficiencies revealed during an inspection conducted on this date. Census was taken

LPA initially arrived to the facility at 8:30 am and took a tour of the facility. At 9:00 am LPA observed a diaper cabinet with different cubbies- a blue fabric cubby had accessible cleaning supplies. Per facility representative the cubby cabinet belongs to the facility but they only use two red cubbies and everything else belongs to the church and it is used on the weekends. LPA advised that all cleaning supplies should be inaccessible to children in care. Items were removed during the inspection.

Based on LPA observations and records review, the following deficiencies listed on the attached LIC 809D (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health and safety.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the facility representative Elizabeth Ramirez

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SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Roxana Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2024
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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Document Has Been Signed on 10/25/2024 11:44 AM - It Cannot Be Edited


Created By: Roxana Lopez On 10/25/2024 at 11:14 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 CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: PASSONS ACADEMY
FACILITY NUMBER: 198020812

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/04/2024
Section Cited
CCR
101238(g)

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101238 Buildings and Grounds (g) Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to children.

This requirement is not met by:
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During the inspection the cleaning items were removed. Per administrator they will meet with the pastor to work out a plan on maintaining that area innacesible to children. A written plan will be submitted to LPA by POC due date of 11/4/24.
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Based on observation and interview the licensee did not comply with the section cited above in that there was a cubby with cleaning supplies accessible to children in care, which poses a potential risk for the health and safety of children in care.
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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:Brandi VanOosten
LICENSING EVALUATOR NAME:Roxana Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2024


LIC809 (FAS) - (06/04)
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