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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304370796
Report Date: 06/07/2023
Date Signed: 06/07/2023 11:19:58 AM

Document Has Been Signed on 06/07/2023 11:19 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:LOS ALAMITOS CDCFACILITY NUMBER:
304370796
ADMINISTRATOR:WERTHEIM,CAROLYNFACILITY TYPE:
850
ADDRESS:12582 KENSINGTON ROADTELEPHONE:
(562) 799-4585
CITY:LOS ALAMITOSSTATE: CAZIP CODE:
90720
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 18DATE:
06/07/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Carolyn Wertheim, District Coordinator/DirectorTIME COMPLETED:
11:45 AM
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
Licensing Program Analyst (LPA) Mila Quinto conducted an unannounced case management incident inspection to follow up on the self-report Unusual Incident dated 4/6/2023. LPA met with Director Carolyn Wertheim. LPA observed 18 preschool children and 2 staff members.

A review of staff criminal clearance records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

On 4/6/2023 a self-reported Unusual Incident Report (UIR) was filed with the Licensing Office. The facility reported that a child eloped out of the playground and exited the school to look for P1.

On 4/20/22, 5/16/23 and 5/17/23, LPA interviewed 5 staff members including the Director. According to the Director, Staff 1 (S1) and Staff 2 (S2) were on the playground with 17 children. S2 was attending to a child by the gate next to the classroom, while S1 was on the playground supervising other children. Child 1(C1) saw the parent by the fence facing the street and came up to the fence to talk. Director stated S1 and S2 did not see C1 leave the playground. Director stated an elementary staff found C1 walking on the elementary grounds towards the office. C1 was found by one of the school districts staff on the elementary school ground near the office. According to S1, a few children were gathered around the fence facing the street where Parent 1(P1) parked. P1 said hello to C1 and headed towards the elementary ground. As the children were saying goodbye, S1 turned back towards the playground area as the children were walking back. S1 did not notice C1 leave the playground. S2 stated was attending to another child on the other side of the playground and did not notice C1 leave the playground. A preschool child pointed towards the elementary ground said, “look there’s C1”. Staff 3 (S3) stated while on her break, a call was received from the school district stating C1 was on the elementary school office with P1. S3 went out to the playground and informed S1 & S2, staff were already aware of C1 leaving the playground. No disclosure from Staff 4 (S4) as staff was not present during the incident.
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Mila Quinto
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: LOS ALAMITOS CDC
FACILITY NUMBER: 304370796
VISIT DATE: 06/07/2023
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
Page 2

On 5/31/23, LPA interviewed Parent 1(P1). According to P1, P1 was dropping off older child at the elementary school and parked on the street by the preschool playground. C1 saw P1 and said hi and proceeded to walk towards the elementary school office. As P1 was walking, P1 found C1 by the school office with another district staff. P1 stated C1 thought C1 was being picked up. P1 stated the staff handled this appropriately and had no concerns.

On 6/7/23, LPA interviewed Child 1(C1). C1 stated when saw mom, C1 ran towards the exit door pointing the gate leading towards the street.

Based on the interviews conducted with 5 staff, Parent 1, Adult 1 and C1, the following deficiency is being cited in accordance with California Code of Regulations, Title 22, Division 12, Section 101229(a)(1) Responsibility for Providing Care and Supervision. The deficiency is being cited on the attached 809D.



This is a Type 'A' violation, shall post and provide copies of the report to parents/guardians of the children in care at the facility by the next business day and shall provide to the parents/guardians of children newly enrolled at the facility during the next 12 months. In addition, the facility shall immediately post upon receipt the Proof of Correction for 30 consecutive days. The licensee is to keep Acknowledgement Receipt (LIC9224) signed by parents in each child’s file.

An exit interview was completed. The report was reviewed and discussed. Appeal Rights were discussed. The facility representative was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the licensing office within 15 business days. The facility representative was informed that the 'Notice of Site Visit' must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100.00. The 'Notice of Site Visit' must be posted on or adjacent to the door. Failure to post Type A Reports for 30 days will result in a civil penalty of $100.00.
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Mila Quinto
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/07/2023 11:19 AM - It Cannot Be Edited


Created By: Mila Quinto On 06/07/2023 at 10:39 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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: LOS ALAMITOS CDC
FACILITY NUMBER: 304370796

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/14/2023
Section Cited
CCR
101229(a)(1)

1
2
3
4
5
6
7
101229 Responsibility for Providing Care and Supervision(a)The licensee shall provide care and supervision... to meet the children's needs.(1)No child(ren) shall be left without the supervision of a teacher at any time...
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Director stated reviewed the supervision videos on CCL website and met with staff individually. The Director is working on a plan to ensure children are being supervised at all times. Director will provide a plan of correction via email to LPA by due date.
8
9
10
11
12
13
14
 According to S1 and S2, C1 eloped out of the playground without supervision. This poses an immediate risk to children in care.
8
9
10
11
12
13
14

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.
SUPERVISOR'S NAME:Patricia Magana
LICENSING EVALUATOR NAME:Mila Quinto
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2023


LIC809 (FAS) - (06/04)
Page: 3 of 3