Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191670506
Report Date: 10/15/2015
Date Signed 10/16/2015 07:48:52 AM

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:ARTESIA HIGH SCHOOL CHILDREN'S CENTERFACILITY NUMBER:
191670506
ADMINISTRATOR:ARLENE RIDDICKFACILITY TYPE:
850
ADDRESS:20651 NORWALK BLVDTELEPHONE:
(562) 229-7959
CITY:LAKEWOODSTATE: CAZIP CODE:
90715
CAPACITY:104CENSUS: 40DATE:
10/15/2015
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Arlene RiddickTIME COMPLETED:
09:45 AM
NARRATIVE
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Licensing Program Analyst, S. Robinson-Horn conducted a Case Management visit to obtain additional information on an incident that occurred on 10.06.15. Upon arrival LPA met with Site Supervisor, Arlene Riddick and informed her of the nature of the visit. The Child Development Coordinator, Amie Wilson Bird arrived during report completion.

Information reported to the Department indicated a child in care was not to be given pork due to religious beliefs and on 10.06.15 the child was given pepperoni pizza for lunch.

During todays visit an interview was conducted with the Site Supervisor and the child's file was reviewed. LPA also obtained copies of supportive documentation.

Based on the information received during todays visit it was determined a child's personal rights was violated when the child was fed pork which conflicted with the families religious beliefs. The child's parent completed a declaration requesting the child not be given pork dated 07.21.15. The facility staff did not receive a copy of this information until 10.06.15.

Based on information observed during todays visit a deficiency of Title 22 Regulations is in violation and is being cited on the attached 809D.

SUPERVISOR'S NAME: Bertha ManzanaresTELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Shameka Robinson-HornTELEPHONE: (323) 980-4930
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2015
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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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 CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: ARTESIA HIGH SCHOOL CHILDREN'S CENTER
FACILITY NUMBER: 191670506
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2015
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/15/2015
Section Cited
101223(a)(3)
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Personal Rights.
Each child shall be free from corporal or unusual punishment, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature.
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Per Child Development Coordinator, training will be provided to staff to ensure all of children's enrollment documentation will be forwarded to the actual facility. There is also a backup system in place called google docs which is a completed electronic file of the children's enrollment information.
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Based on information received and an interview conducted it was determined a child's personal rights was violated when the child was fed pork on 10.06.15. The child's parent requested the child not be fed pork on a declaration dated 07.21.15. The facility staff was not informed of this information until 10.06.15 after the incident occurred.
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This system will now be utilized as a back-up system. The Teaching staff will now be required to review the google docs system each time a new child is enrolled to ensure that paper file mimics the electronic file. The child's paper file has since been updated.
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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: Bertha ManzanaresTELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Shameka Robinson-HornTELEPHONE: (323) 980-4930
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2015
LIC809 (FAS) - (06/04)
Page: 2 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: ARTESIA HIGH SCHOOL CHILDREN'S CENTER
FACILITY NUMBER: 191670506
VISIT DATE: 10/15/2015
NARRATIVE
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  • Upon receipt of the licensing report, Licensee shall post report documenting Type A citation(s) along with Notice of Site Visit Form in an area accessible for review for 30 days or a civil penalty of $100 will be assessed.
  • Licensee shall also provide a copy of the report documenting Type A citation(s) to all parents of currently enrolled children along with form LIC 9224 (Acknowledgement of Receipt of Licensing Report) for signature. Completed form shall be placed in child's file.
  • Licensee shall also provided report and form to parents of newly enrolled children for the next 12 months.

Exit Interview completed and Appeal Rights Discussed with Site Supervisor, Arlene Riddick and CD Coordinator, Amie Wilson Bird.
SUPERVISOR'S NAME: Bertha ManzanaresTELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Shameka Robinson-HornTELEPHONE: (323) 980-4930
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2015
LIC809 (FAS) - (06/04)
Page: 3 of 3