Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198013177
Report Date: 02/03/2017
Date Signed 02/03/2017 11:01:35 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:MARY ALICE O'CONNOR CCLCFACILITY NUMBER:
198013177
ADMINISTRATOR:AMANDA EDWARDSFACILITY TYPE:
830
ADDRESS:401 N. BUENA VISTA STREETTELEPHONE:
(818) 846-1063
CITY:BURBANKSTATE: CAZIP CODE:
91506
CAPACITY:20CENSUS: 17DATE:
02/03/2017
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:06 AM
MET WITH:Amanda EdwardsTIME COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Anomeh Eivazian conducted an unannounced case management visit today, to deliver findings for two incidents that occurred on 11/18/16 and it were reported to the Licensing Department on 11/21/16. LPA met with Amanda Edwards, Director who guided analyst on a tour of the facility.

1. On 11/18/16, a parent informed the Director that she witnessed staff # 1 picked up child #2 by one arm to lift child #1 up.
2. On 11/18/16, staff #2 informed the Director that she witnessed child #1 got few reminders from staff #1 to have gentle hands with other children, staff #1 went over to help child #1 and walked child #1 from the library area of the classroom near the bathroom, and staff #1 went to knees and talked to child #1 to have gentle hands with other children, staff #1 was tapping on the child hand.

During the course of investigation, interviews were conducted with Director, staff #2 and staff #3.
During the course of investigation there were no disclosures regarding incident #1.

Based on staff #2 interview, staff #1 tapped on child#1 hand. Written declaration was obtained from staff #2 on 01/18/17.

Based on staff #3 interview, staff #3 heard staff #1 was talking to child #1 regarding listing to the teachers, it was kind of stern thing, it was not intentionally to hurt child #1, it was more reminder to listen to the teachers. Staff #3 heard staff #1 tapped on child #1 twice, once while staff #3 was getting something from diaper area, and second time while staff #3 was in the kitchen area. Written declaration was obtained from staff #3 on 01/18/17.
REPORT CONTINUES ON NEXT PAGE 1 of 2
SUPERVISOR'S NAME: Christina GabelmanTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Anomeh EivazianTELEPHONE: (323) 981-3391
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2017
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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: MARY ALICE O'CONNOR CCLC
FACILITY NUMBER: 198013177
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/06/2017
Section Cited
101223(a)(1)
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Personal Rights: Each child shall be accorded dignity in his/her personal relationships with staff, and other persons.

Based on this investigation, it was found that staff #1 did tap on child #1 hand while staff
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Per Director, two training were conducted in December 2016 staff meeting on Positive Child Guidance and Mandated Child Abuse reporting. Sign in sheet was provided to LPA.
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#1 was showing gentle touch to child #1 to have gentle touch with other children.

This poses an immediate Health and Safety risk to children in care
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Per Director, there will be a reminder on Possible Child Guidance and Child Abuse Mandated reporting on a monthly basis.

Plan of correction was cleared during this visit.
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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: Christina GabelmanTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Anomeh EivazianTELEPHONE: (323) 981-3391
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2017
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: MARY ALICE O'CONNOR CCLC
FACILITY NUMBER: 198013177
VISIT DATE: 02/03/2017
NARRATIVE
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Per Director, staff #1 was interviewed on 11/28/16 and stated that staff #1 asked child #1 to show the gentle touch , but staff #1 did not tap on the child#1 hand. Staff #1 was placed under pending suspension and pending investigation. Based on school Policy reviewed, staff #1 got separated from the school on 12/14/16. Staff #1 last day in the classroom was the day of incidents, 11/18/16.

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

Based on LPA observation and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore 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.

Upon receipt of this report, the Director shall post the Notice of Site visit and any licensing report documenting a type “A” deficiency. The report and the Notice of Site visit shall be posted for 30 consecutive days. Failure to maintain posting as required, will result in an immediate $100 civil penalty. A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled children for the next 12 months (1 year). The Acknowledgement form must be maintained in each child’s file immediately upon receipt from parent. Director was provided with a copy of the parent Acknowledgement of Receipt of Licensing Reports Form during this visit.

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.
REPORT END 2 of 2
SUPERVISOR'S NAME: Christina GabelmanTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Anomeh EivazianTELEPHONE: (323) 981-3391
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2017
LIC809 (FAS) - (06/04)
Page: 2 of 3