Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198018831
Report Date: 02/23/2017
Date Signed 02/23/2017 11:23:18 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:PINE TREE PRESCHOOLFACILITY NUMBER:
198018831
ADMINISTRATOR:ANGIE GOMEZFACILITY TYPE:
850
ADDRESS:311 S. NORMANDIE AVE.TELEPHONE:
(213) 365-0909
CITY:LOS ANGELESSTATE: CAZIP CODE:
90020
CAPACITY:63CENSUS: 36DATE:
02/23/2017
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Angie Gomez TIME COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Seung Lee conducted an unannounced random inspection. LPA met with Angie Gomez, Director who guided analyst on tour of facility. This is a preschool program with a toddler component which consists of 4 classrooms.

Dragon Fly : Staff #1, with 3 toddlers; Monkey Class: Staff #2, #3 and #4 with 18 preschoolers; Bunny: Staff #5 and #6 with 5 preschoolers; Chipmunk: Staff #7, #8, and #9 with 10 preschoolers. The following was observed during tour of facility:

PHYSICAL PLANT

Disinfectants, cleaning solutions, medication and other items that are dangerous to children, were inaccessible to children. Director states that poisons are stored in a locked room. Furniture and equipment are in good condition, free of sharp, loose, or pointed parts. All toilets and hand washing sinks are safe, sanitary and are operating properly. All floors are clean and safe.

All kitchen areas/food preparation areas and food storage areas are kept clean and are free of litter, rubbish and rodents and/or any other vermin. All storage containers for solid waste, including moveable bins shall have tight-fitting covers that are kept on, and in good repair. Trash cans used to discard food have tight fitting lids. Drinking water is readily available both indoors and outdoors. The facility was observed to be free of flies, other insects and rodents.



Outdoor playground equipment is in safe condition, free of sharp, loose or pointed parts. The surface of the outdoor activity space is maintained in a safe condition and is free of hazards. All areas around or under high climbing equipment, swings, slides, and similar equipment are cushioned with material that absorbs a fall. There is adequate shade in the play yard.

REPORT CONTINUES ON THE NEXT PAGE 1 OF 2
SUPERVISOR'S NAME: Cassandra CooperTELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Seung LeeTELEPHONE: (323) 981-3412
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2017
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 2


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: PINE TREE PRESCHOOL
FACILITY NUMBER: 198018831
VISIT DATE: 02/23/2017
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FACILITY RECORDS
All individuals present have obtained a criminal record clearance or criminal record exemption. There is at least one person trained in CPR and Pediatric First Aid present during this visit. Educational background, training, and/or experience for each staff present are on file and were reviewed.

In review of children’s records, files contain information including, but not limited to the following: Name, address and telephone number of the child's authorized representative and of relatives or others who can assume responsibility for the child if the authorized representative cannot be reached when necessary.

Snack menus are posted one week in advance where it is visible by the child's authorized representative. Menus for the past 30 days are available upon request. Snacks were reviewed for availability, quantity and appropriateness to children in care. Some children enrolled bring their own breakfast and lunch. The facility provides breakfast, lunch and PM snack.

Incidental Medial Services (IMS). Licensee states that prescription and non-prescription medications are administered. Medication is stored in the kitchen. Medications administered does include prescription inhalers and Epi-Pens. Therefore, the facility does offer not Incidental Medial Services (IMS). LPA advised the licensee that an amendment to the current plan of operation must be submitted in 30 days. Please refer to Section 101173 and 101226 for further information on regulatory requirements

All staff have immunization up to date on file.

There were no deficiencies cited during today’s 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, Director, including, but not limited to Provider Rights, Appeal Procedures and Agencies Consultative Role.

REPORT CONTINUES ON THE NEXT PAGE 2 OF 2
SUPERVISOR'S NAME: Cassandra CooperTELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Seung LeeTELEPHONE: (323) 981-3412
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2017
LIC809 (FAS) - (06/04)
Page: 2 of 2