Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198013177
Report Date: 01/18/2017
Date Signed 01/18/2017 02:46:11 PM

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:MARY ALICE O'CONNOR CCLCFACILITY NUMBER:
198013177
ADMINISTRATOR:THEODOROPOULOS, C.FACILITY TYPE:
830
ADDRESS:401 N. BUENA VISTA STREETTELEPHONE:
(818) 846-1063
CITY:BURBANKSTATE: CAZIP CODE:
91506
CAPACITY:20CENSUS: 16DATE:
01/18/2017
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Amanda EdwardsTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Anomeh Eivazian conducted an unannounced case management visit today, due to incidents that occurred on 11/18/2016. LPA met with Amanda Edwards, Director during this visit.
Alleged Incidents took place on 11/18/16. School Director , Amanda Edwards was informed about both incidents on 11/21/16 by a parent and staff #2.

Incidents were reported via telephone same working day on 11/21/16. The written incident reports were received by mail on 11/28/16. The facility reported the incident within the required 24 hour time frame.

LPA observed the area where alleged incidents took place. LPA conducted interviews with Director, Amanda Edwards and teachers, staff #2 and staff #3. Declarations were obtained from staff #2 and staff #3. LPA obtained a copy of staffs conference memorandums and follow up training sing in sheet.

Due to insufficient information available at this time, both incidents need further investigation.

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. Exit interview was conducted with Amanda Edwards, Director, including, but not limited to Provider Rights, Appeal Procedures and Agencies Consultative Role.

SUPERVISOR'S NAME: Christina GabelmanTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Anomeh EivazianTELEPHONE: (323) 981-3391
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2017
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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