Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198001578
Report Date: 05/04/2018
Date Signed 05/04/2018 10:22:25 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:CHILD EDUCATIONAL CENTER, CALTECH/JPL COMMUNITYFACILITY NUMBER:
198001578
ADMINISTRATOR:SHAKE AMZOYANFACILITY TYPE:
840
ADDRESS:250-56 S. MICHIGANTELEPHONE:
(818) 354-3418
CITY:PASADENASTATE: CAZIP CODE:
91106
CAPACITY:42CENSUS: 0DATE:
05/04/2018
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Cheryl Darnel, School-Age TeacherTIME COMPLETED:
10:40 AM
NARRATIVE
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Licensing Program Analyst (LPA) Anomeh Eivazian conducted an unannounced case management inspection today, due to an incident that occurred on Thursday, 03/29/18. Shake Amzoyan, Site Director was not present during this inspection. LPA met with Cheryl Darnel, after-school teacher who guided analyst on a tour of the facility. During this inspection, preschool program children with facility number 198016427 were present on the premises. During this inspection LPA talked to Allegra Inganni, Program Director in the main office who also assisted during this inspection.

Alleged Incident took place on Thursday, 03/29/18. Incident was not reported via telephone next working day, it was reported on Tuesday, 04/03/18. Original LIC 624 Unusual Incident/Injury Report form was received by the Department within 7 days. The written incident report was received by mail on Thursday 04/05/18. The incident report was dated for Thursday , 04/05/18. The facility did not report the incident within the required 24 hour time frame. Per Program Assistant Director, Talar Tchoboien, she tried to fax the report on 04/02/18 but got a busy signal from fax.

LPA observed the area where alleged incident took place. (Pictures were taken). LPA conducted an interview with staff#1 who was present on the playground at the time of the incident.

Per staff # 1, who witnessed the incident, she was in the sand box with about 8 to 10 children and it was about transition time to clean up the area and everyone were helping to put toys away. Child # 1 was in the sand box, towards the wall. Child#2 tossed a container into the storage crate it belonged in, the item accidentally hit child#1 on the right side of the head. Per staff#1, at the time of the incident staff #1 was in the sand box 15-20 feet away cleaning up with other children. The incident occurred really quick that staff#1 was not able to prevent the incident. At the time of the incident staff#2 was also on the playground. Child#1 came to staff#1 and explained what had happened.
REPORT CONTINUES ON THE NEXT PAGE 1 OF 2
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Anomeh EivazianTELEPHONE: (323) 981-3391
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2018
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: CHILD EDUCATIONAL CENTER, CALTECH/JPL COMMUNITY
FACILITY NUMBER: 198001578
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2018
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/04/2018
Section Cited
CCR
101212(d)
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Reporting Requirements.

A report shall be made to the Department within 24 hours of the occurrence of any unusual incident as specified.
On Thursday, 03/29/18 child#1 got injured on the right side of the head, and
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Per Program Director, reporting requirements will be reviewed with staff and incidents will be reported in a timely manner from now on.
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received 3 staples. The incident was reported to CCL on Tuesday, 04/03/18 via phone and written report was received via mail on 04/05/18. Incident was not reported in a timely manner.
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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: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Anomeh EivazianTELEPHONE: (323) 981-3391
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2018
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2018
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: CHILD EDUCATIONAL CENTER, CALTECH/JPL COMMUNITY
FACILITY NUMBER: 198001578
VISIT DATE: 05/04/2018
NARRATIVE
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Staff#1 checked the child#1's head and observed blood on the right side of the head. Staff #1 escorted child#1 to the office, Site Director Shake Amzoyan checked the child#1 head, and observed a nick on the right side of the child #1's head. Injury area was cleaned, first aid was applied, parents were informed. Child#1 was picked up at 6:00 PM. Child#1 was taken to Urgent Care and received 3 staples.

Ratio and staffing were in accordance of Title 22 Code of Regulations at the time of the incident. At the time of the incident there were 18 children present with 3 staff.

LPA issued the Confidential Names List (LIC 811) to the licensee during this inspection. The Confidential Names List documents the staff and children involved with the incident documented in this report.

Based on this information, the following deficiencies listed on the attached LIC 809d 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 & safety.

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.

Allegra Inganni, Program Director was on the phone while LPA read the report.

Exit interview was conducted with Cheryl Darnell, School-age teacher, including, but not limited to Provider Rights, Appeal Procedures and Agencies Consultative Role.
REPORT END 2 OF 2
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Anomeh EivazianTELEPHONE: (323) 981-3391
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2018
LIC809 (FAS) - (06/04)
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