Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198018831
Report Date: 05/11/2017
Date Signed 05/11/2017 01:16:41 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: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:
05/11/2017
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Angie GomezTIME COMPLETED:
01:26 PM
NARRATIVE
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Licensing Program Analyst (LPA) Seung Lee conducted an unannounced case management incident inspection. Upon arrival LPA Lee met with Director Angie Gomez who guided the analyst on a tour of the facility.

It was disclosed through an incident report, that two children from the same family were involved in a separate incident that occurred on 02/13/2017 and 02/14/2017. On 02/13/2017 a child hit his head on a shelving cubby while playing outside with a basketball. The child was given first aid, and parent was notified. On 02/14/2017 the other child, the first child's older sister, was involved in a hair cutting incident with other children. The child cut her own hair and cut the hair of one other child. The parent of the child was notified of the incident that same day.

02/28/2017 was the last day for both children at the facility. The children were picked up by the parent and never returned. At that time there was no prior notice or a reason given for the children not coming back.

On 03/18/2017 The school received an email from the parent of these two children stating that the facility had discriminated against their two children and therefore wanted a refund of all the tuition made to the facility.

The Director stated that the incidents that occured on the 13th and 14th of February were not reported because she felt they did not qualify as an unusual incident or a serious injury. After the Director had a chance to see the email sent to the school on the 18th of March, she decided to call and report the two incidents on 03/27/2017.

SUPERVISOR'S NAME: Cassandra CooperTELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Seung LeeTELEPHONE: (323) 981-3381
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2017
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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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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/11/2017
Section Cited
101212(d)(1)(C)
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Reporting Requirements.

Any unusual incident or child absence that threatens the physical or emotional health or safety of a child shall be reported to the Department within 24 hours of the occurrence.
An incident that had occured was not reported
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The Director stated that she will call in incidents in the future wihtin the 24 hour period.
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to the deparment within 24 hours. This is a potential risk to children in care.
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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: Cassandra CooperTELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Seung LeeTELEPHONE: (323) 981-3381
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2017
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: PINE TREE PRESCHOOL
FACILITY NUMBER: 198018831
VISIT DATE: 05/11/2017
NARRATIVE
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LPA Lee advised the Director to report all incidents involving children getting hurt or cutting hair in the future. LPA Lee advised that these type of incidents should be reported to the department in a timely manner no matter how small the injury or if the parent had no issues with the incidents.

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.

Exit interview was conducted with Angie Gomez, Director, including, but not limited to Provider Rights, Appeal Procedures and Agencies Consultative Role.
SUPERVISOR'S NAME: Cassandra CooperTELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Seung LeeTELEPHONE: (323) 981-3381
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2017
LIC809 (FAS) - (06/04)
Page: 3 of 3