LIS055 LIC~NSING INFORMATION SYSTEM - FACILITY PROFILE DATE: 10/02/14 EVALUATOR: 2213 DO: 33 FAC NBR: 19 1200190 STATUS: LICENSED FAC NAME: CHILDREN'S COUNTRY HOUSE CAPACITY: 0034 FAC ADDR: 2821 SANTA ROSA, ALTADENA, CA 91001 FAC MAIL: 3835 LANDFAIR ROAD, PASADENA, CA 91107 FAC TYPE: DAY CARE CENTER CLIENT SERVED: CHILDREN/INFANT FAC FIRST LICENSED: 03/01/93 APP REC'D: COUNTY: LOS ANGELES DIRECTOR: NIELSON, DEBERA PHONE: (626)798-8083 DATE CAP CHG: 07/23/04 DATE CAP APPR: ANNUAL FEES CURRENT: YES LICENSEE NAME: NIELSON, DEBERA LIC MAIL: 3835 LANDFAIR ROAD, PASADENA, CA 91107 LIC EFF DATE: ·03/01/93 TYPE: INDIVIDUAL FAC DUAL IDE~~IFIER: N DUAL LICENSE NBR: FCRB: COMMENTS LAUP FACILITY. LICENSEE PREFERS TO SERVE CHILDREN AGES 2 THROUGH 8 YEARS. AMBU"~TORYONLY. CAPACITY INCLUDES 30 PRESCHOOL AGE CHILDREN AGES 2 THROUGH 5 YEARS, AND 4 SCHOOL AGED CHILDREN AGES 6 TO 8 YEARS OLD. FAC CLOSED DATE: E-MAIL: LAST VISIT DATE: 09/30/14 TYPE: PLAN OF CORRECTION LAST DEFERRED VISIT DATE: TYPE: SUPPLEMENTARY PERSONAL HISTORY: 000 REQUIRED VISIT: N Enter> R = ME:ro, Y = DATES, F = SUMMARY, H = PAYMENT HISTORY, E= EMERGENCY STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF SOCIAL SERVICES 1000 CORPORATE CNTR DR. 200-B MONTEREY PARK, CA 91754 EDMUND G. II!ROWN JR. C\O'JERNC•~ October 02, 2014 CHILDREN'S COUNTRY HOUSE- 191200190 38~5 LANDFAIR ROAD PASADENA. CA 91107 Dear Dr. Nielson, I am writing in regards to your recent request to adjust the ages of school age children served from 6 to 8 years old to 6 to 12 years old. In a recent review of your file for public review, it has come to my attention that the age range was limited not by our Department but by the Fire Marshall on 4/25/1995. A copy is enclosed for your review. Although you do not presently have any adults living upstairs, compliance and adherence to the local laws and Title 22 regulations are needed if you wish to remain in operation. Failure to do so will lead to possible administrative action on the part of the Department. Sincerely, E. Ann Dumolt COPY DISTRIBUTION: STATE FIRE MARSHAL FIRE SAFETY INSPECTION REQU, STD 850 (REV. 8186) r 1-3-STATE FIRE MARSHAL 2-FIRE AUTHORITY 4-5-liCENSING AGENCY D_,?ARTMENT OF SOCIAL SERVICES CARE LICENSING DIVISION l'",S !\tH>ELES CHILD DAY CARE EACT ~~· J FLAIR DRIVE, SUITE 200 r~ 1 • :. :'TiE CA 91731 (~ '~) 575·6603 ;;.~r!!.1UNITY 10. AGENCY NAME AND ADDRESS L * AGE RPJmE 2 T'lmtJ. 8 YRS. * VERY POOR CONDITIONS - 2 ADULTS LIVE UPSTAIRS. WOOD PILES BEHIND BUILDING •. 2821 S COUNTRY HOUSE SANTA ROSA 1. GACH 2. GACH/A 8. 9. 10. 11. 12. 13. 3. SH 4. APH ALTADENA, CA 91001 5. PHF 6. SNF ICF/DD ADHC CLINIC JAIL ICF/DDN OrnER TO BE COMPLETED BY INSPECTING AUTHORITY 18. FIRE I AUTHOR NAME AND ADDRESS L LOS ANGELES COUNTY FIRE DEPT. 7733 S. GREENLEAF AVE. WHITTIER, CA 90602 INSPECTOR GABRIEL RAMERIZ I _J 1 CODES TO BE COMPLETED BY INSPECTING AUTHORtTY 10 NO. !0. REGH?N, OFFICE! AND ADDRESS L _j CLASS STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES . COMMUNITY CARE LICENSING DMSION CCLD Regional Office 1000 CORPORATE CNTR DR. 200-B MONTEREY PARK, CA 91754 10/01/2014 CHILDREN'S COUNTRY HOUSE 191200190 3835 LANDFAIR ROAD PASADENA, CA 91107 Letter of Deficiency Citations Cleared Dear Licensee 1 The following deficiencies, initially cited during a visit on 02/04/2014, have been cleared: Section Cited: 101215.1(m) Plan of Correction: Director states, Pediatric First Aid/ CPR will be scheduled and completed. Send a copy of completion certificate to LPA by POC Date Due: 03/04/2014 Corrections: Copy of Certificate sent Clearance Date: 03/03/2014 Date Due: 03/04/2014 Corrections: Copy of certificate (card) sent Clearane& Date: 03/03/2014 date Section Cited: 101216(1) Plan of Corre·ction: Oire:tor states, Pediatric First Ald/CPR will be scheduled and completed. Send a copy of completion certificate to LPA by POC date. Section Cited: 101238(a) Plan of Correction: Date Due: 03/04/2014 Corrections: Director states will sand and refinish all wood structure by the POC date. Picture sent of structure Section Cited: 101239 (f) (1) Plan of Correction: Director states will have Ught fitting lids on all trash cans were food is discarded. Date Due: 02/04/2014 Corrections: LICENSING EVALUATOR NAME: EAnn Dumolt Clearance Date: 03/03/2014 Picture sent of trash can with tlght fitting lid. Clearance Date: 03/03/2014 TE!-EPHONE: (323) 240-6201 LICENSING EVALUATOR SIGNATURE: DATE: 10/01/2014 This report must be available at Child Care and Group Home facllltles for public review for 3 years. Clea."ed POC Letter(FAS) ·(04105) Page: 1 of1 STATE OF CAUFORNIA ·HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FACILITY EVALUATION REPORT CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B MONTEREY PARK, CA 91754 .FACILITY NAME: CHILDREN'S COUNTRY HOUSE ADMINISTRATOR: NIELSON, DEBERA ADDRESS: 2821 SANTA ROSA ALTADENA CITY: CAPACITY: 34 TYPE OF VISIT: POC MET WITH: Rebecca Robledo, Ass1 Director FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: STATE: CA CENSUS: 9 DATE: UNANNOUNCED TIME BEGAN: TIME COMPLETED: 191200190 850 (626) 798-8083 91001 09/30/2014 08:30AM 09:45AM NARRATIVE Licensing Program Analysts Ann Dumolt and Teresa Licon returned to clear a deficiency cited on 9/2412014. Citation was a repeat violation for flies being all over the play yard and in the animal pens. This resulted in civil penalties being assessed. Licensee, Dr. Nielsen, emailed LPA Dumolt the following day to state that the fly issue has been resolved. 1 2 3 4 5 6 7 LPA 's Dumolt and Licon toured facility. Indoors the facility is stuffy but otherwise fly free. The play yard was toured. Equipment is relatively clean (yard has areas of loose dirt and dust can easily be kicked up). Staff clean the play equipment daily. Flies on this visit are present but contained to the animal pens. The number of flies is substantially reduced, for example, on the 9/24/2014 visit one could estimate 25 flies per 1 square foot. on this visit, 3 flies per 1 square foot. LPA Dumolt researched the literature to determine if it is reasonable to have a fly free animal pen. Literature only speaks of "acceptable levels." In other words, there -will always be flies but steps can be taken to reduce their numbers: removal of vegetable waste (in the case of the Licensee--goat and pony solid waste as well as keeping the pens dry a much as possible from the urine). Licensee-ensures the pens are cleaned daily through staff or parent volunteers. Apple cider vinegar is sprayed on the play equipment to keep the flies off. A repellent is sprayed on the goats and pony in the evenings to keep the flies off of them. 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 In light of the above, deficiency is cleared as of 9/25/2014. Civil penalties are therefore assessed and stopped at $50.00. Another follow up will be made in 30 to 60 days to ensure that Licensee is in compliance with keeping up sanitation in and around the facility and the yard. Failure to do so will result in citations and immediate civil penalty of $150 per citation with $50 per citation each day the deficiency is not corrected. Copy of report, appeal rights, and exit interview given. 24 25 SUPERVISOR'S NAME: Joan Hayes TELEPHONE: (323) 981-3360 LICENSING EVALUATOR NAME: EAnn Dumolt TELEPHONE: (323) 240-6201 LICENSING EVALUATOR SIGNATURE: ZA-~~1 DATE: 0913012014 I acknowledge receipt of this fonm and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2014 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC8~9 (FAS) • (06/04) P.age: 1 of1 STATE OF CAUFORNIA ·HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FACILITY EVALUATION REPORT CCLD Regional Offlce,1000 CORPORATE CNTR DR. 200-B MONTEREY PARK, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE ADMINISTRATOR: NIELSON, DEBERA ADDRESS: 2821 SANTA ROSA CITY: ALTADENA CAPACITY: 34 TYPE OF VISIT: POC MET WITH: Rebecca Robledo 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 FACILITY NUMBER: FACILITY TYPE: TELEPHONE: STATE:CA ZIP CODE: CENSUS: 9 DATE: UNANNOUNCED TIME BEGAN: TIME COMPLETED: 191200190 850 (626) 798-8083 91001 09/24/2014 08:30AM 10:05 AM NARRATIVE Teresa Licon and Ann Dumolt LPA's conducted a plan of correction visit today to ensure that the citations issued on 9/9/2014 have been corrected. Due dates were 9/23/2014 Debera Nielson, designated director was not present upon LPA's arrival, LPA's met with Rebecca Robledo. LPA's observed the following: o Metal play equipment had been temporarily fixed o Shelves in back room has been cleaned. • Webs have been cleaned off the tree house and slide The above citations have been cleared and a Letter of Deficiencies Cleared was provided to the licensee during this visit. • flies are still in the playground and there were in the pony corral and goat corral this is a repeat violation civil penalties will be accessed until corrected o Pony corral has some improvement but feces was still present (attracting flies) this is a repeat violationcivil penalties will be accessed until corrected The deficiencies listed on the following pages were observed by the LPA and are being cited in accordance with'Califomia Code of Regulations Title 22. Please see attached LIC 809d Deficiencies that are being re-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 reprehensive. Failure to maintain posting as required will result In a civil penaltv of $100.00. Exit interview was conducted with Debera Nielson, Director, A copy of this report and appeals rights were explained and provided. SUPERVISOR'S NAME: Joan Hayes TELEPHON : (323) 981-3380 LICENSING EVALUATOR NAME: Teresa Licon TELEPHONE: 323-229-6521 LICENSING EVALUATOR SIGNATURE: /6(~~~ DATE: 09/24/2014 FACILITY REPRESENTATIVE SIGNATURE: fl!!- A:-...._____ DATE: 09/24/2014 This report must be available at Child Care and Group Home facilities for public review for 3 years. UCS09 {FAS) ~ (06104) Page: 1 of 2 STATE OF CALIFORNIA • HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSING DMSION FACILITY EVALUATION REPORT CCLD Regional Offlce,1000 CORPORATE CNTR DR. 200-B MONTEREY PARK, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE ADMINISTRATOR: NIELSON, DEBERA ADDRESS: 2821 SANTA ROSA CITY: ALTADENA CAPACITY: 34 TYPE OF VISIT: POC MET WITH: Debera Nielson 1 2 3 4 5 8 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 STATE: CA CENSUS:9 UNANNOUNCED FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 191200190 850 (628) 798-8083 91001 09/09/2014 08:30AM 11:30 AM NARRATIVE Teresa Licon and Ann Dumolt LPA's conducted a plan of correction visit today to ensure that the citations issued on 8/28/2014 have been corrected. Due dates were 8/29/14 and 9/4/2014. Debara Nielson, designated director was not present upon LPA's arrival, but arrived shortly after. LPA's met with Rebecca Robledo upon arrival. LPA observed the following. • • • • • Cleaner has been removed and place in a inaccessible area. Director did spray a fogger on date of visit but flies are still in the playground . Medications have bean removed and place in a inaccessible area. Animal corral has some improvement but needs to be maintained Bathroom has been cleaned of debris. o Personnel records- have been completed • Limitations on Capacity- 9 year old child is no longer at facility The above citations have been cleared and a Letter of Deficiencies Cleared was provided to the licensee during this visit. The deficiencies listed on the following pages were observed by the LPA and are being c~ed in accordance ~ California Code of Regulations Title 22. Please see attached LIC 809d Deficiencies that are being re-cited need to be cleared to protect the children's health & safety. The Notice of Site Visit (LIC 9213)- must remain posted for 30 davs during the hours of operation after each site visit by a licensing reprehensive. Failure to maintain posting as required will result In a civil penalty of $100.00. Exit interview was conducted with Debera Nielson, Director, A copy of this report and appeals was explained and provided. SUPERVISOR'S NAME: Joan Hayes TELEPHONE: (323) 981-3380 LICENSING EVALUATOR NAME: Teresa Licon TELEPHONE: 323-229-6521 DATE: 09/09/2014 I acknowledge receipt of this form and understand my licensing appeal rights as explained and recelv11d. FACILITY REPRESENTATIVE SIGNATURE: 'IV~ DATE: 09/09/2014 This report must be available at Child Care and Group Home facilities for public review for 3 years. UC809 (FAS) • (06104) Page: 1 of 3 STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DMSKlN FACILITY EVALUATION REPORT (Cont) COLD Regional Offk:a, 1000 CORPORATE CNTR DR.200-B MONTEREY PARK, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE DEFICIENCY INFORMATION FOR THIS PAGE: Doflcloncy Type POC Due Date I FACILITY NUMBER: 191200190 VISIT DATE: 09/24/2014 DEFICIENCIES PLAN OF CORRECTJONS(POCs) Section Number Type A 10/01/2014 Section Cited 101238(a)(1) 1 Buildings and Grounds. The licensee shall take 1 Lead Teacher Rebecca Robledo stated she will free of flies, other consult with tack and feed to find a solution to 2 measures to keep the center 2 1 3 insects and rodents. LPA s observed flies all over 3 reduce the amount flies 4 the pony corral and the goat corral and on the 4 Facility will also use vinegar and water solution to 5 playground. 5 reduce the files 6 This is a repeat violation civll penalties will be 6 7 accessed of $50.00 a day until corrected 7 Type A 10/01/2014 Section Cited 101238(a) 1 2 3 4 5 6 7 Buildings and Grounds. The child care center shall be clean, safe, sanitary and in good repair at all times. LPA's observed allot of feces which attract flies In the pony corral. This is a repeat violation civil penalties will be accessed of $50.00 a day until corrected 1 Rebecca Robledo will to continue to maintain the 2 corral clean and dry. 3 Facility will clean on a dally basis. 4 5 6 7 1 2 3 4 5 6 7 1 2 3• 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 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: Joan Hayes TELEPHONE: (323) 981-3380 LICENSING EVALUATOR NAME: Teresa Licon TELEPHONE: 323-229-6521 LICENSING EVALUATOR SIGNATURE: l·f>4.-.~~ DATE: 09/24/2014 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATNE SIGNATURE: DATE: 09/24/2014 This Notice must be posted for 30 days LICS09 (FAS. • (06104) Page: 2 of 2 STATE OF CAUFORNIA- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVJCES COMMUNITY CARE LICENSING DIVISION FACILITY EVALUATION REPORT (Cont} CCLD Regional Office, 1000 CORPORATE CNTR DR. 200·8 MONTEREY PARK, CA. 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE DEFICIENCY INFORMATION FOR THIS PAGE: Deficiency Type POC Due Date I FACILITY NUMBER: 191200190 VISIT DATE: 09/09/2014 PLAN OF CORRECTIONS(POCs) DEFICIENCIES Section Number .1 Buildings and Grounds. The child care center shall 1 Director stated she will have someone clean the TypeB 09/23/2014 Section Cited 101238(a) 2 be clean, safe, sanitary and In good repair at all 3 times. The back classroom LPA's observed that 4 dust is still on shelves in the classrooms 5 6 7 2 shelves In the classrooms 3 4 5 6 7 Type B 09/23/2014 Section Cited 101238(a) 1 2 3 4 5 6 7 1 Director stated she is going to spray on the 2 weekends and will also wipe the webs away 3 4 5 6 7 Buildings and Grounds. The chlld care center shall be clean, safe, sanitary and in good repair at all times. LPA observed that the slide on the tree house is stlll full of webs. The tree house also has webs on it. 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 1 2 3 4 5 6 7 7 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: Joan Hayes TELEPHONE: (323) 981-3380 LICENSING EVALUATOR NAME: Teresa Licon TELEPHONE: 323-229-6521 LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2014 FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2014 UC!l09 (FAS)- {06104) Page: 2 of3 All POC Have Been Cleared STATE OF CAUF.ORNIA ~HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSING DMSION CLEARED DEFICIENCIES CCLO Regional Office, 1DDD CORPORATE CNTR OR. 2DD-B MONTEREY PARK, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE FACILITY NUMBER: 191200190 VISIT DATE: 09/09/2014 POC Due Date I Section Number 09/2312014 101238(a) Date Cleared I Comments PLAN OF CORRECTIONS(POCs) 1 2 1 ~ ~!rector stated she will have someone clean the shelve~ in the 2 LPA observed 6 4 5 classrooms 3 ~r~;4h12ad01b4een c1eaned 7 09123/2014 Section Cited 101238(a) 1 2 ~ Director stated she is going to spray on the weekends and wlll 5 ~lso wipe the webs away 6 7 ~ 3 4 1 Section Cited Section Cited 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 1 2 3 4 0912412014 LPA observed webs had been removed STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DMSION CCLD Regional Office 1000 CORPORATE CNTR DR. 200-B MONTEREY PARK, CA 91754 09/24/2014 CHILDREN'S COUNTRY HOIJSE 191200190 3835 LANDFAIR ROAD PASADENA, CA 91107 Letter of Deficiency Citations Cleared Dear Licensee, The following deficiencies, inHially cited during a visit on 09/09/2014, have been cleared: Section Cited: 101238(a) Date Due: 09/23/2014 Plan of Correction: Corrections: Clearance Date: Director stated she Will have someone clean the shelves In the classrooms LPA observed area had been cleaned 09/24/2014 Section Cited: 1 01238(a) Plan of Correction: Director stated she is going to spray on the weekends and will also Dale Due: 09/23/2014 Corrections: Clearance Date: LPA observed webs had been removed 09/24/2014 wipe the webs away LICENSING EVALUATOR NAME: Teresa Licon TELEPHONE: 323-229-6521 LICENSING EVALUATOR SIGNATURE: t DATE: 09/24/2014 This report must be available at Child Care and Group Home facilities for public review for 3 years. Cleared POC Letter {FAS) {04/05) M Pago: 1 of 1 CAUFORNIA DEPARTMENT OF SOCIAl SERVICES COMUUNITY CARE UCENSING DIVISION STATE OF CALIFORNIA" HEALTH AND HUMAN SERVlCES AGENCY FACILITY EVALUATION REPORT (Cont) CCLD Regional Offlce,1000 CORPORATE CNTR DR. 200-1!. MONTEREY PARK, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE DEFICIENCY INFORMATION FOR THIS PAGE: Deficiency Typo POC Due Date I FACILITY NUMBER: 191200190 VISIT DATE: 09/09/2014 PLAN OF CORRECTIONS(POCs) DEFICIENCIES Section Number Type A 09/23/2014 Section Cited 101238.2(d)(2) Type A 09/23/2014 Section Cited 101238(a)(1) Type A 09/23/2014 Section Cited 101238(a) 101238.2(d)(2) Outdoor Activity Space. Outdoor activity space shall be hazard free. 1 2 3 4 5 6 7 1 2 3 The metal equipment In the play area has corrusion 4 and part of the bottom has been broken off. this is 5 a Risk to the health & safety of children and they 6 can seriously cut them themselves on this 7 1 2 3 4 Buildings and Grounds. The licensee shall take measures to keep the center free of flies, other Insects and rodents. Even thou there was some improvement the flies are still in the corral, play Director stated she wlll have the equipment. repaired and in the mean while she will wrpp yellow tape around the equipment to preven children from getting on the equipment equipment 1 Director stated she will continue to have the 2 maintance person come every other day 3 4 5 ground, and LPA observed in the parking lot 5 6 7 6 7 1 2 3 4 1 Director stated she will continue to have the 2 maintance person come every other day to clean 3 the corrals 4 Buildings and Grounds. Th~ child care center shall be clean, safe, sanitary and in good repair at all times. Even thou there was some Improvement at the 5 time of visit there was still allot of feces which 6 attract flies in the pony corral. 7 1 2 3 4 5 6 7 5 6 7 1 2 3 4 5 6 7 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: Joan Hayes TELEPHONE: (323) 981-3380 LICENSING EVALUATOR NAME: Teresa Licon TELEPHONE: 323-229-6521 LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2014 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2014 This Notice must be posted for 30 days UCS09 (FAS)- (06/04) Page: 3of 3 To Clear Additional POC's Use Button on 809-D STATE OF CAUFORNIA ~HEALTH AND HUMAN SERVICES AGENCY CLEARED DEFICIENCIES CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DMSION CCLD Regional Office, 1000 CORPORATE CNTR DR. 200·B MONlEREY PARK. CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE FACILITY NUMBER: 191200190 VISIT DATE: 09/09/2014 POC Due Date I Section Number 09/23/2014 101238.2(d)(2) Date Cleared I Comments PLAN OF CORRECTIONS(POCs) 1 2 3 Director stated she will have the equipment repaired and in the 4 mean while she will wrap yellow tape around the equipment to 5 6 reven children from getting on the equipment 1 3 the area of the metal equipfT!ent 4 7 09/23/2014 Section Cited 101238(a)(1) 1 2 3 1 2 4 Director stated she will continue to have the malntance person 3 5 !come every other day 6 4 7 09/23/2014 Section Cited 101238(a) 1 2 ~ Section Cited 1 Director stated she will continue to have the maintance person 2 3 5 come every other day to clean the corrals 6 7 1 2 3 4 5 6 7 09/24/2014 2 LPA observed director did tape around 4 1 2 3 4 STATE OF CALIFORNIA~ HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMeNT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DMSION CCLD Regional Office 1000 CORPORATE CNTR DR. 200-B MONTEREY PARK, CA 91754 09/24/2014 CHILDREN'S COUNTRY HOUSE 191200190 3835 LANDFAIR ROAD PASADENA, CA 91107 Letter of Deficiency Citations Cleared Dear Licensee, The following deficiencies, initially cited during a vistt on 09/09/2014, have been cleared: Section Ctted: 101238.2(d}(2} Plan of Correction: Director stated she wi!l have the equipment repaired and In the mean while she will wrap yellow tape around the equipment to preven chil::lren from getting on the equipment LICENSING EVALUATOR NAME: Teresa Licon Date Due: 09/23/2014 Corrections: Clearance Date: LPA observed director did tape around 09/24/2014 the area of the m~tal equipment TELEPHONE: 323-229-6521 LICENSING EVALUATOR SIGNATURE: DATE: 09/2412014 This report must be available at Child Care a(ld Group Home facilities for public review for 3 years. Clazred POC Letter (FAS)- (04105) Page: 1 of 1 STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION COMPLAINT INVESTIGATION REPORT CCLD Regional Offlca,1000 CORPORATE CNTR DR. 200-B MONTEREY PARK, CA 91754 This is an official report of an unannounced visit/investigation of a complaint received in our office on 09/03/2014 and conducted by Evaluator EAnn Dumolt COMPLAINT CONTROL NUMBER: 33-CC-20140903110251 FACILITY NAME: CHILDREN'S"COUNTRY HOUSE ADMINISTRATOR: NIELSON, DEBERA ADDRESS: 2821 SANTA ROSA CITY: ALTADENA CAPACITY: 34 MET WITH: STATE: CENSUS:9 UNANNOUNCED Debera Nielson, Director FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: 191200190 850 (626) 798-8083 91001 09/09/2014 08:30AM 11:30 AM ALLEGATION($): 1 Physical Plant: There are files and mosquitoes at facility and it is extending into the neighborhood. 2 Animal pens are full of feces that is attracting files. 3 4 5 6 7 8 9 INVESTIGATION FINDINGS: 1 Licensing Program Analysts Dumolt and Licon met with Dr. Nielson to address the above allegations. 2 Licensee stated that a representative from Vector Control came out to the facility last Friday. Mosquito larve 3 was found in the water pail for the pony. Small water tub used for ducks to drink and bathe did not have any 4 evidence of mosquito larve but Licensee was instructed to empty it out after each use to prevent mosquitos 5 from using it as a breeding ground. Representative went through the property (behind the children's yard) and 6 pointed out other potential habitats for Mosquito Larve. Licensee indicated that over this past weekend she had 7 the back area cleared of old tires and other items that could collect water. The representative's name and 8 phone number was given to LPA Dumolt. Representative will be returning on or about 9/20/2014 to follow up 9 with Licensee. 10 11 LPA's Dumolt and Licon toured the yard. Pony pen had feces covering about half the pen. Flies, though not 12 as numerous in the past, were observed in the pen, through out the yard, in the parking lot, and in the facility 13 Ducks were noted to be penned up--water and food within their enclosure. The small tub used for ducks to bathe in was empty and turned over. Substantiated SUPERVISOR'S NAME: Joan Hayes Estimated Days of Completion: TELEPHONE: (323) 981·3380 LICENSING EVALUATOR NAME: EAnn Dumolt TELEPHONE: (323) 240·6201 LICENSING EVALUATOR SIGNATURE: DATE: 0910912014 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: kik1~'-h~ DATE: 09/09/2014 This report must be available at Child Care and Group Home facilities for public review for 3 years. Control Number 33-CC-2014090311 0251 STATE OF CAUFORNIA ·HEALTH A.ND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSING DIVISION COMPLAINT INVESTIGATION REPORT (Cont) CCLO Regklnal Offlce,100D CORPORATE CNTR DR. 200-B MONTEREY PARK, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE DEFICIENCY INFORMATION FOR THIS PAGE: FACILITY NUMBER: 1912001.90 VISIT DATE: 09/09/2014 Deficiency Type Type A 09/2312014 Section Cited 101238(a)(1) PLAN OF CORRECTIONS(POCs) DEFICIENCIES PDC Duo Date I Section Number 1 2 3 4 Buildings and Grounds The licensee shall take measures to keep the center free of flies and other insects. Animal pens are not cleaned dally to reduce the number of flies 5 attracted by feces e,specially of the pony (goat and 6 duck pens reasonably clean). Also standing water, 7 i.e,. pony's 8 water was found to have mosquito larve during an 9 inspection made by an vector central officer .. 10 11 12 13 14 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 2 3 4 4 5 6 7 5 6 7 1 2 3 4 1 2 3 4 5 5 6 7 During visit. fly traps changed by maintenace worker but pony's pen nat cleaned aut. licensee states she will ensure pony's pen is cleaned daily. 1 2 3 6 7 Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in · a c!vll penalty assessment. TELEPHONE: (323) 981-3380 SUPERVISOR'S NAME: Joan Hayes LICENSING EVALUATOR NAME: EAnn Dumolt TELEPHONE: (323) 240-6201 LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2014 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2014 This Notice must be posted for 30 days UC9099 (FAS) (OB104) M Page: 2 of 3 Control Number 33-CC-2014090311 0251 STATE OF CALIFORNIA· HEALTH ANO HUMAN SERVICES AGENCY CAUFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION COMPLAINT INVESTIGATION REPORT (Cont} CCLD Regional Offk:o, 1000 CORPORATE CNTR DR. 200-8 MONTEREY PARK, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE FACILITY NUMBER: 191200190 VISIT DATE: 09/09/2014 NARRATIVE 1 Based on today's visit and past visits, Complaint allegations are substantiated. 2 3 4 The following are deficiencies according to theCA Code of Regulations, Title 22, Division 12, Chapter 1: (see following page}: 5 6 7 Copy of report, appeal rights, and exit interJiew given. 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 SUPERVISOR'S NAME: Joan Hayes TELEPHONE: (323} 981-3380 LICENSING EVALUATOR NAME: EAnn Dumolt TELEPHONE: (323) 240-6201 LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2014 I acknowledge receipt of this form arid understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: ~~~ UC9::!99 (FAS) -(06104) DATE: 09/09/2014 Page: 3 of 3 STATE OF CAUFORNIA ·HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSING DIVISION FACILITY EVALUATION REPORT FACILITY NAME: CHILDREN'S COUNTRY HOUSE ADMINISTRATOR: NIELSON, DEBERA 2821 SANTA ROSA ADDRESS: CITY: ALTADENA CAPACITY: 34 TYPE OF VISIT: Annual/Random Debra Nielson MET WITH: 1 2 3 4 5 6 7 8 9 10 11 CCLD Regional Office, 1000 CORPORATE CNTR DR. 200·8 MONTEREY PARK, CA 91754 FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: STATE:CA CENSUS: 13 DATE: UNANNOUNCED TIME BEGAN: TIME COMPLETED: 191200190 850 (626) 798-8083 91001 08/28/2014 10:00 AM 02:30PM NARRATIVE (2) Teresa Licon, and Ann Dumolt Licensing Program Analysts (LPAs) conducted an unannounced Random Visit on this date. Met with facility Director, Debra Nielson who guided analyst tour of the facility. All areas identified on the Facility Sketch were inspected. Furniture and equipment was inspected for age appropriateness and good repair. Telephone service, heating, lighting and ventilation were evaluated. Napping equipment and bedding was inspected for good condition, appropriate storage and cleanliness. Storage for children's belongings and an isolation area with a sink, toilet in the hallway. Children bring their water bottles everyday, however facility provides water if children run out. Age appropriate sinks and toilets were inspected for availability, good repair, toilet paper, area safety and sanitation. Snack/lunch menus were reviewed. Food and snacks were reviewed for availability,-quantity and appropriateness to children in care. I Cleaning compounds are stored in the laundry area and are inaccessible to children. There was a bettie of Fantastic cleaner in the 2yr old classroom. Outdoor equipment was inspected for safety, cushioning material, good repair and appropriateness. Outdoor equipment was observed to have spider webs. Natural shade was observed drinking water fountain and fencing were inspected. 12 13 14 15 16 17 18 19 20 Play area was inspected for hazards and inaccessibility to bodies of water. This facility has 3 Goats, 1 Pony 21 and 1 Rabbit. 2 Geese All animals are kept in corrals. However the Corral where the.Pony is kept was full of 22 feces. Flies surrounded the area where the animals are kept and in part of the children's play area .. 23 24 Teacher child ratios were observed to be In compliance with Title 22 California Code of Regulations. Sign in 25 and out sheets were observed and reviewed. SUPERVISOR'S NAME: Joan Hayes TELEPHONE: (323) 981-3380 LICENSING EVALUATOR NAME: Teresa Licon TELEPHONE: 323-229-6521 LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2014 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: r&).L DATE: 08/28/2014 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC8(19 (FAS) ~ (OG/tl4) Page: 1 of 5 STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CALIFORNiA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DMSION FACILITY EVALUATION REPORT (Cont) CCLD Regional Office, 1000 CORPORATE CNTR DR. 20D-B MONTEREY PARK, CA 91754 FACILI1Y NAME: CHILDREN'S COUNTRY HOUSE DEFICIENCY INFORMATION FOR THIS PAGE: FACILI1Y NUMBER: 191200190 VISIT DATE: 08/28/2014 Deficiency Type POC Due Date I DEFICIENCIES PLAN OF CORRECTIONS(POCs) Section Number Type A 08128/2014 Section Cited 101238(g) Type A 08129/2014 Section Cited 101238(aX1) Type A 08/28/2014 Section Cited 101226(e)(1 )(A) Type A 08/29/2014 Section Cited 101238(a) 1 2 3 4 5 6 7 Buildings and Grounds. Disinfectants, cleaning solutions, poisons and other items that are dangerous to children shall be inaccessible to children. in the 2 year old class there was a bottle of fantastic on the shelf where It was accessible to children. This is a risk to the Health & Safety of children 1 Director removed the bottle and place it on a top 2 shelf high enough where it is not accessible to 3 children. 4 5 6 7 1 2 3 4 5 6 7 Buildings and Grounds. The licensee shall take measures to keep the center free of flies, other insects and rodents. In the childrens play area and where the animals ~re kept LPA's observed flies all around. 1 2 3 4 5 6 7 1 2 3 4 5 6 7 Health Related Services 1 Director moved the medication container to a high 2 shelf where it becomes Jnacessible to children 3 4 5 6 7 1 2 3 4 5 6 7 Medications shall be kept in a safe place inaccessible to children. The medications were on a 4th level shelf in the hallway and easily assesible to children Ibuprofen, insect repellent, sunscreen. This is a risk to the Health & Safety of Children. Director sprayed a fogger to kill the flies. Director will continure to fog every morning they have a malntalnce man every other day replenslhes the fly traps Buildings and Grounds. The chl!d care center shall 1 Director Stated that she will have the maintance 2 man come and clean the corral. be clean, safe, sanitary and in gcod repair at all 3 times. LPA observed that The Animal ccral fer the Pony was full of feces. 4 5 6 7 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: Joan Hayes TELEPHONE: (323) 981-3380 ·LICENSING EVALUATOR NAME: Teresa Licon TELEPHONE: 323-229-6521 DATE: 08/28/2014 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILI1Y REPRESENTATIVE SIGNATURE: DATE: 08/28/2014 This Notice must be posted for 30 days UC609 (FAS) ~ (06/04) Page: 2 of 5 All POC Have Been Cleared STATE OF CALIFORNIA· HEALTH AI:ID HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT Of SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CLEARED DEFICIENCIES CCLO Regional Office, 1000 CORPORATE CNTR DR, 200-B MONTEREY PARK, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE POC Due Date/ FACILITY NUMBER: 191200190 VISIT DATE: 08/28/2014 Date Cleared I PLAN OF CORRECTIONS(POCs) Section Number 08/28/2014 101238(g) Comments 1 2 3 Director removed the bottle and piace it on a top shelf high 4 5 enough where it is not accessible to children. 6 7 08129/2014 Section Cited 101238(a)(1) 1 2 3 Director sprayed a logger to kill the flies. 4 Director will continure to fog every morning they have a 5 maintaince man every other day replensihes the fly traps 6 1 08/28/2014 2 Cleared By Visit~ Director corrected on 3 date of visit 4 09/09/2014 Cleared By Visit ~ director did spray 1 however problem has not been corrected 2 there are flies in the corral and on play ~ ground LPAs observed some in the back room. 7 08/28/2014 Section Cited 101226(e)(1 )(A) 1 2 ~ 5 6 1 08/28/2014 Director moved the medication container to a high shelf where 2 Cleared By Visit - Director corrected on 3 date of visit t becomes inacessible to children 4 7 08/29/2014 Section Cited 1D1238(a) 1 ~ !Director Stated that she will have the maintance man come 4 3nd clean the corral. 5 6 7 09/09/2014 1 Cleared By Visit - on visit date coral was ~ better but needs to be maintan on a daily basis - 4 STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DMSION CCLD Regional Office 1000 CORPORATE CNT.R DR. 200-B MONTEREY PARK, CA 91754 09/09/2014 CHILDREN'S COUNTRY HOUSE 19i200i90 3835 LANDFAIR ROAD PASADENA, CA 91t07 Letter of Deficiency Citations Cleared Dear Licensee, The following deliciencies, initially cited during a visit on 08/28/2014, have been cleared: Section Cited: 101238(g) Plan of Correction: Director removed the bottle and place it on a top shelf high enough where !! is not accessible to children. Section Cited: 101238(a)(1) Plan of Correction: Director sprayed a fogger to k111 the flies. Dlre::tor will continure to fog every morning they have a malntaince man every other day raplensihes the fly traps Section Cited: 101226(e)(1XA) Plan of Correction: Director moved the medication container to a high shetf where It becomes Jnacesslble !o children Section Cited: 101238(a) Plan of Correction: Director Stated that she will have the ma!ntance man come and clean the corral. LICENSING EVALUATOR NAME: Teresa Licon Date Due: 08/28/2014 Corrections: Clearance Date: Cleared By Visit- Director corrected on 08/28/2014 date of visit Date Due: 08/29/2014 Corrections: Cleared By Visit- director did spray however problem has not been corrected there are flies in the corral and on play ground LPAs observed some in the back room. Clearance Date: 09/09/2014 Date Due: 08/28/2014 Corrections: Clearance Date: Clearad By Visit- Director corrected on 08/28/2014 date of visit Date Due: 08/29/2014 Corrections: Clearance Date: Clearad By Visit- on visit date coral 09/09/2014 was better but needs to be maintan on a daily basis ~ TELEPHONE: 323-229-6521 LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2014 This report must be available at Child Care and Group Home facilities for public review for 3 years. Cleared POC Letter (FAS) • (04/05) Page: 1 of 1 STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIA.L SERVICES COMMUNITY CARE LICENSING DMSION FACILITY EVALUATION REPORT (Cont) CCLD Regional Office, 1000 CORPORATE CNTR DR. 20o.B MONTEREY PARK, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE FACILITY NUMBER: 191200190 VISIT DATE: OB/28/2014 NARRATIVE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 Procedures were reviewed with director regarding well ness checks for 9hildren. First Aid supplies were observed. Per director medicine is only administered when accompanied with a doctor's note. Verification of CPR/First Aid and health preventative practices for opening and closing staff was observed to be current. Inspection of required forms made for staff, including qualifications for staff. were conducted. Inspection of required forms for children was inspected LPA checked criminal background clearances for staff. The deficiencies listed on the following pages were observed by the LPA and are being cited in accordance with California Code of Regulations Title 22. Please see attached LIC 809d Deficiencies that are being cijed need to be cleared to protect the children's health & safety The licensee shall furnish each parent a copy of the Type A citation, parent will need to sign the acknowledgment statement indicating that he/she has received the documents and the date they were received. The licensee shall keep verification of receipt in each child's file. LPA advised licensee how to access forms and regulations on line at: www.ccid.ca.qov. The Notice of Site Visit (LIC 9213)- must remain posted for 30 davs during the h0 urs of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penaltv of $100.00. Exit interview was conducted with Debra Nielson Director, The director read this report and report was also explained and provided by LPA 28 29 30 31 32 SUPERVISOR'S NAME: Joan Hayes TELEPHONE: (323) 981-3380 LICENSING EVALUATOR NAME: Teresa Licon TELEPHONE: 323-229-6521 LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2014 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2014 UC809 (FAS) * (06104) Page: 3 of 5 STAlE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSING DIVISION FACILITY EVALUATION REPORT (Cont) CCLC Regional Office, 1000 CORPORATE CNTR DR. 200-B MONTEREY PARK, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE DEFICIENCY INFORMATION FOR THIS PAGE: Deficiency Type POC Due Date I FACILITY NUMBER: 191200190 VISIT DATE: 08/28/2014 PLAN OF CORRECTIONS(POCs) DEFICIENCIES Section Number Type B 08/28/2014 Section Cited 101239(e)(4) TypeB 09/04/2014 Section Cited 101238(a) TypeB 08/29/2014 Section Cited 101238(a) TypeB 08/29/2014 Section Cited 101217(a) 1 2 3 4 5 6 7 1 Director stated she will clean the area. She stated Fixtures, Furniture, Equipment and Supplies. All toilets, hand-washing and bathing faciJities shall be 2 that some work was being done in the bathroom 3 kept in safe and sanitary operation and shall be ADA compliant. LPA observed the bottom of the 4 toilet with Particles of debris where children can put 5 6 In their mouth 7 1 2 3 4 5 6 7 Buildings and Grounds. The chlid care center shall be clean, safe, sanitary and in good repair at all times. LPA observed book shelfs in the 3 yr old classroom and the back classroom to be very dusty. 1 Director stated that she will do a through cleaning 2· 3 4 5 6 7 1 2 3 4 5 6· 7 Buildings and Grounds. The child care center shall be clean, safe, sanitary and in good repair at all times. The Tree house with slide and other play equipment all had spider webs 1 Director stated that she will clean off the childrens 2 equipments and remove all spider webs. 3 To ensure that this keeps clean she .will have one 4 of her teachers clean 5 6 7 1 Personnel Records. Personnel records shall be 2 maintained on the licensee, administrator, and 3 each employee, and shall contain specified 4 5 6 7 1 Director Stated that she will have the teachers 2 complete a fonn and place In their files. 3 information. 4 LIC 508 Criminal Record statement was missing fo 5 Nancy Winston, Julie Weingarten. 6 LIC 9052 Employee righs missing -Jessica 7 Rowland,Nancy Winston,Jule Weingarten 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: Joan Hayes TELEPHONE: (323) 981-3380 LICENSING EVALUATOR NAME: Teresa Licon TELEPHONE: 323-229-6521 LICENSING EVALUATOR SIGNATURE: ~~~·~~ DATE: 08/2812014 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACI~VESIGNATURE: DATE: 0812812014 ucsd!f'l" (06104) Page: 4 of 5 To Clear Additional POC's Use Button on 809-D STATE OF CAUFORNIA ·HEALTH AND HUMAN SERVICES_ AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSING DIVISION" CLEARED DEFICIENCIES CCLD Reglonal Office, 1000 CORPORATE CNTR DR. 200-B MONTEREY PARK, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE FACILITY NUMBER: 191200190 VISIT DATE: 08/28/2014 POC Due Date I Section Number 08/28/2014 101239(e)(4) Date Cleared I Comments PLAN OF CORRECTIONS(POCs) 1 2 ~ Director stated she will clean the area. She stated that some r.vork was being done in the bathroom 5 6 1 09/09/2014 2 Cleared By Visit- LPA observed the 3 bathroom to be cleaned of debris 4 7 09/0412014 Section Cited 101238(a) 1 2 3 4 Director stated that she will do a through cleaning 5 6 7 08/2912014 Section Cited 101238(a) 1 2 3 4 1 ~ Director stated that she will clean off the childrens equipments 4 ~nd remove all spider webs. 5 Ira ensure that this keeps clean she will have one of her 6 eachers clean 1 2 3 4 7 08/29/2014 1 Section Cited ; 101217(a) 1 ,09/09/2014 . . Director Stated that she will have the teachers complete a form 2 Cleared By ViSit~ LPA observed m1ssmg 4 and place in their files. 3 orms to be completed 5 6 7 4 STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CAUFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DMSION CCLD Regional Office 1000 CORPORATE CNTR DR. 200-B MONTEREY PARK, CA 91754 09/09/2014 CHILDREN'S COUNTRY HOUSE 191200190 3835 LANDFAIR ROAD PASADENA, CA 911 07 Letter of Deficiency Citations Cleared Dear Licensee, The following deficiencies, initially cited during a visit on 08/28/2014, have been cleared: Section Cited: 101239(e)(4) Plan of Correction: Date Due: 08/28/2014 Corrections: Director stated she wiU clean the area. She stated that some work was being done in the bathroom Cleared By Visit- LPA observed the Section Cited: 101217(a) Plan of Correction: Director Stated that she will have the teachers complete a form and place In their files. LICENSING EVALUATOR NAME: Teresa Licon Clearance Date: 09/0912014 bathroom to be cleaned of debris Date Duo: 08/2912014 Corrections: Clearance Date: Cleared By Visit- LPA observed 09/0912014 missing fonns to be completed TELEPHONE: 323-229-6521 LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2014 This report must be available at Child Care and Group Home facilities for public review for 3 years. Chmlld POC Letter (FAS)- (04/05) Page: 1 of 1 STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY CAUFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNiTY CARE LJCENSING DIVISION FACILITY EVALUATION REPORT (Cont) CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-8 MONTEREY PARK. CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE DEFICIENCY INFORMATION FOR THIS PAGE: Deficiency Type POC Due Date I Section Number Type A 08/28/2014 Section Cited 101161(a) FACILITY NUMBER: 191200190 VISIT DATE: 08/28/2014 DEFICIENCIES PLAN OF CORRECTIONS(POCs) 1 Limitations on Capacity and Ambulatory Status. 2 The licensee shall not exceed the conditions, 3 limitations and capacity specified in the license. 4 LPA observed that a 9 year old child was on the 5 premises. This is exceeds the condition of license 6 where it states that facility will have children from 2 7 to 8 years old 1 Director stated that she will ~ubmit a application to 2 range to age 12. 3 Child will no longer be here as of tomorrow 4 5 6 7 1 2 3 4 5 6 7 1 2 1 2 1 2 3 4 5 6 7 3 4 5 1 2 1 2 3 4 5 6 7 3 4 5 6 7 3 4 5 6 7 6 7 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: Joan Hayes TELEPHONE: (323) 981-3380 LICENSING EVALUATOR NAME: Teresa Licon TELEPHONE: 323-229-6521 LICENSING EVALUATOR SIGNATURE: I·~~ DATE: 08128/2014 FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/2812014 This Notice must be posted for 30 days UC809 (FAS) • (OG/04) Paee: s of 5 All POC Have Been Cleared STATE OF CAUFORNIA- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTfdEtfT OF SOCIAL SERVICES COMMUNITY CARE UCENSING DIVISION CLEARED DEFICIENCIES CClD Regional Office, 1000 CORPORATE CNTR DR.20D-B MONTEREY PARK, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE FACILITY NUMBER: 191200190 VISIT DATE: 0812812014 POC Due Date I Date Cleared I Comments PLAN OF CORRECTIONS(POCs) S&ctlon Number 08/28/2014 1D1161(a) Section Cited 1 2 3 Director stated that she will submit a application to range to 4 ~ge 12. 5 fchHd will no longer be here as of tomorrow 6 7 1 2 3 4 5 6 7 1 09/09/2014 2 Cleared By Visit • The 9 year old child is 3 no longer at facility. 4 1 2 3 4 1 Section Cited Section Cited 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 1 2 3 4 STATE OF CAUFORNIA- HEALTH AND HUMAN SERVICES AGENCY CAUFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING OMSION CCLD Regional Office 1000 CORPORATE CNTR DR. 200-B MONTEREY PARK, CA 91754 09/09/2014 CHILDREN'S COUNTRY HOUSE 191200190 3835 LANDFAIR ROAD PASADENA, CA 91107 Letter of Deficiency Citations Cleared Dear Licensee, The following deficiencies, initially cited during a visit on 08/28/2014, have been cleared: Section Cited: 101161(a) Plan of Correction: Date Due: 08128/2014 Corrections: Dlr!!ctor stated that she will submit a application to range to age 12. ChTid will no longer be here as of toino!TOYI Cleared By VIsit- The 9 year old child is no longer at facility LICENSING EVALUATOR NAME: Teresa Licon Clearance Date: 09/09/2014 TELEPHONE: 323-229-6521 LICENSING EVALUATOR SIGNATURE: I DATE: 09/09/2014 This report must be available at Child Care and Group Home facilities for public review for 3 years. Cleared POC Letter (FAS)- (04/05) Page: 1 of 1 STAiE OF CAUFORNIA- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FACILITY EVALUATION REPORT CCLD Regional Office, 1000 CORPORATE CNTR DR. 200.S MONTEREY PARK, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE ADMINISTRATOR: NIELSON, DEBERA ADDRESS: 2821 SANTA ROSA ALTADENA CITY: CAPACITY: 34 TYPE OF VISIT: Case Management MET WITH: Debera Nielson 1 2 3 4 5 6 7 FACILITY NUMBER: FACILITY TYPE: TELEPHONE: STATE:CA ZIP CODE: DATE: CENSUS: 13 UNANNOUNCED TIME BEGAN: TIME COMPLETED: 191200190 850 (626) 798-8083 91001 08/28/2014 10:00 AM 02:30PM NARRATIVE LPA's Dumolt and Licon visited facility for the purpose of reviewing and signing amended reports for complaint investigated on 6/20/2014 and on 6/06/2014; and to amend citations given on 5/09/2014 during a case management visit. For the Case Management Visit conducted ong 5/09/2014, citations for the sign in/ out sheets and the lack of tight fitting lids on trash cans in the classrooms used for disposing food and soiled diaper were changed from Type A to type 8 as these citations were not deemed to be immediate harm to children in care .. 8 9 For the complaint report on 6/06/2014, complaint determination was changed from unfounded to 10 substantiated on the allegation that a parent volunteer was used a teacher. The report was amended 11 separately from the original report due to other allegations listed as unfounded. A citation was issued on the 12 amended report. 13 14 For the complaint report on 6/20/2014, the determination was changed from inconclusive to substantiated. 15 The naport was amended to reflect why this determination was changed. As this was an amended report, a 16 citation is being made on this report. 17 18 The following is a deficiency according to theCA Code of Regulations, Title 22, Division 12, Chapter 1 (see 19 next page). The citation, Personal Rights violation resulted in the injury of a child. This is considered a "Zero 20 Tolerance" violation and an immediate Civil Penalty is being assessed. Appeal Rights given. 21 22 Copy of this report and the amended reports listed above, appeal rights, and exit interview given. 23 24 25 TELEPHONE: (323) 981-3380 SUPERVISOR'S NAME: Joan Hayes LICENSING EVALUATOR NAME: EAnn Dumolt TELEPHONE: (323) 240-6201 LICENSING EVALUATOR SIGNATURE: ~~~~ DATE: 08/28/2014 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: ~ DATE: 08/28/2014 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC809 (FAS} ~ (D61Q4) Pago; 1 of 2 STATE OF CAUFORNIA • HEALTH AND HUUAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSING DMSION FACILITY EVALUATION REPORT (Cont) COLD Regional Office, 1000 CORPORATE CNTR DR. 2DO-B MONTEREY PARK,. CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE DEFICIENCY INFORMATION FOR THIS PAGE: Deficiency Type POC Due Date I FACILITY NUMBER: 191200190 VISIT DATE: 08/28/2014 PLAN OF CORRECTIONS(POCs) DEFICIENCIES Section Number Type A 08/2812014 Section Cited 101223(a)(3) 1 2 3 4 5 On or about 5/05/2014, a Teacher#2 heard a child 5 6 6 crying In another room. Teacher#3 was 7 7 1 2 3 4 8 9 10 11 12 13 14 Personal Rights. Each child shall be free from corporal or unusual punishment, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature. in this room shouting at the child. Teacher#2 observed the child had a bloody lip. When Teache #2 asked what had happened., Teacher#3 stated the child "ran into [her] knuckle." (Refer to Confiden~al Names dated 6106/2014 page 1-ccpy printed out and given to Dr. Nielson. 1 2 3 4 5 6 7 1 2 3 4 Dr. Nielson states she believes the story to be false. On the date In quest!on she does not recall the child had a bloody lip nor did the child complain of an injury or report the injurry to her or staff or to his mother. Immediate Civil Penalties of $150 asssed as a child was injured as the result of '[running 8 into teachcher's] knuckle." Appeal Rights 9 expliained. Dr. Nielson stated that she will appeal. 10 11 12 13 14 1 2 3 4 5 6 7 1 2 3 4 5 5 6 7 6 7 Failure to correct the cited deflciency(ies), on or before the Plan of Correction (POC) due date, may result In a civil penalty assessment. SUPERVISOR'S NAME: Joan Hayes TELEPHONE: (323) 981-3380 LICENSING EVALUATOR NAME: EAnn Dumolt TELEPHONE: (323) 240-6201 LICENSING EVALUATOR SIGNATURE: ~iht"""' s..t, 11100 Colp. Ctr. Dr. - B COMPLAINT INVESTIGATION REPORT (Cont) FACIUTY NAME: CHILDREN'S COUNTRY HOUSE DEFICIENCY INFORMATION FOR THIS PAGE: Type l'l!on Cited 10123a(a)1 c- 1 1 During 1he review of 1lle lllaff flk>"! ft "'"" ~ 1het nor !he college where they ware taken 2 6 7 7 1 Ret~ were~ In tile-r In 1he holwey. This 1 2 b an immediate hoefth hazard to tile (llllldren, ostile fUmes 3 itom 1he facility nor does She have proof of being a fully qualified teacher. The review of tile stafi files indicated lila! 3 thera courses but the pspsr work does not indicate what tile cl re0111ipt !If this form and undenrt;~nd my appeal righttl\ as explained and rocelved. ,. /'I fACIUTY REPRI:SENTATIVE SIGNATUREJ. /J. , (. I i < l L-..-... DATE: 08/10/2004 Page: 1 of1 STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CALIFORN!A DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING OMS ION FACILITY EVALUATION REPORT LA Child Care East, 1000 Corp. Ctr. Dr.#200B Monte FACILITY NAME: CHILDREN'S COUNTRY HOUSE ADMINISTRATOR: NIELSON, DEB ERA ADDRESS: 2821 SANTA ROSA CITY: ALTADENA CAPACITY: 34 TYPE OF VISIT: MET WITH: Debra Nielson Park, CA 91754 FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: STATE:CA DATE: CENSUS: 16 UNANNOUNCED TIME BEGAN: TIME COMPLETED: 191200190 850 (818) 798-8083 91001 06/10/2004 01:00PM NARRATIVE 1 2 Duling the course of a complaint visn the application for the toddler option was discussed and area re-looked at. Duling the visit the follow were discussed as well as observed. 3 4 5 1. In the bathroom the changing table was not observed. Changing table was observed in a storage room. Applicant indicated that she will move to bathroom so that it is within arms reach of water. 6 7 8 2. Discipline description will be amended to reflect what actual steps will be taken as to how children will be disciplined (actual manner of discipline) 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24. 25 3. Needs and service plan will be amended to actually reflect who was interviewed and acknowledgme.nt of receipt. During this visn the facility was not measured either indoors or outdoor. SUPERVISOR'S NAME: Georgia Brown TELEPHONE: (323)981-3369 LICENSING EVALUATOR NAME: Karen Chambers TELEPHONE: (323)981-3368 LICENSING EVALUATOR SIGNATURE: -SIGNED-* DATE: 06/1 0/2004 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: -SIGNED- DATE: 06/10/2004 This report must be available at the facility for public review (3 years). UC801 (FAS) • (00/04) Page: 1 of 1 OAU!'ORIMDI!PAATWIENTOF I!QCIAI.llEIWICES CQMMUiliTY CAAl! I.ICENOIIIGI DIVIS !OM LA Chl/;1 C.. Eacf, 1000 ecr,.. C~. Dr. ti:ICOB FACILITY EVALUATION REPORT FACIUTY NAIIIE:CHILOREN'S COUNTRY HOUSE DIReCTOR: NIELSON, OEBERA ADDRESS: 2821 ~NTA ROSA CITY: ALTADENA CAPACITY: 34 TYPE OF VISIT: Prelicenlling MEl" WITH: Debra Nielson -Pm.CAt1764 STATE: CA CENSUS: 16 UNANNOUNCEO DEFICIENCY INFORMATIOIII FOR THIS PAGE: FACILITY NUMBER: FACIUTY TYPE: TELEPHONE: ZIP CODE: 191200190 850 (818) 798-8083 91001 06/10/2004 01:00PM DATE: TilliE BEGAN: TIME COMPLETED: CIVIL PENALTY INFORMATIOIII: COIIIMENTSIOEFICIENCIES 1 2 During tho course of a complaint visit the appfK:alion fOr the toddler option was discussed and area re-fooked at. During the visit !he foffow were discussed as well as observed. 3 4 5 6 1. In the bathroom the changing table was not observed. Changing table was observed in a storage room. Applicant indicated that she will move to bathroom so that it is•within rums reach of water. 7 2. Oi$cipline description will be amended to reflect whet actus! steps will be taken as to how children will be disCiplined (ectual manner of discipline) 8 9 10 11 12 13 3. Needs and service plan will be amended to actually reflect who was intE!rvilmed and acknowledgment of receipt. During this visit the faclllly was not measured either Indoors or outdoor. 14 15 16 17 18 19 20 21 22' 23/ Failuns to comtct the cited defWiency(ie£), on or bi!fwc the Plan of Correction (POCJ due date, chril penalty l'lSSEISIImon!. TELEPHONE: (323)981-3369 SUPERVISOR'S NAME: Georgia Brown UCENSING EVALUATOR NAME: Ka~ UCENSING EVALUATOR SIGNATU 11'111~ t118Uit ~.&-~ TELEPHOIIIE: (323)981·3368 DATE: 06/10/2004 laclmowledga n!C81pt of this form and unllerstand· my licofllling appo~l rights as explainad and mceivod. ;·V,./'.,. . (J2.. L, FACILITY REPReSENTATIVE SJGr./ATURe: I! , DATE: 06/1012004 in a All POC Have Been Cleared STATE OF CAU~ORNJA- HEALTH AND HUMAN SERVICES AGENCY CAL!.FORNIA DEPARTMENT OF SOCIAL SERVICES 'COMMUNITY CARE LICENSING OMSION CLEARED POC's LA Child care East, 1000 Corp. Ctr. Dr. #200B Monterey Park, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE FACILITY NUMBER: VISIT DATE: 06/16/2004 POC Due Date I SacUon Number PLAN OF CORRECTIONS(POCs) 1 2 3 4 ~EPLACE MESH MATERIAL oe/17/2004 101238(a)1 5 6 Date Cleared Comments 1 I 08104/2004 2 ~issing mesh material was observed 3 4 uring this visit 7 oe/23/2004 Section Cited 101238(a) 1 2 3 4 ~EPAIR OR REPLACE DOOR 5 6 0810412004 1 2 Door in toddler room was observed to 3 have been repaired during this visit 4 7 08123/2004 Section Cited 101238(a) 1 2 3 4 PROPERLY SECURE AREA. 5 6 1 08104/2004 2 !There is a rod Iron fence surrouf"Jdlng the 3 small patio outside the toddler room 4 7 07!01/2004 Section Cited 101238(a) 1 2 3 REPAIR FLOOR BOARDS. PROVIDE COPY OF WORK 4 5 bRDER UPON COMPLETION 6 7 08104/2004 1 Floor boards appear to have been ~ repaired. When LPA stepped on the floor 4 It did not appear to give STATE OF CALIFORNIA~ HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIV1SJON FACILITY EVALUATION REPORT (Cont) LA Chlkl Caru Eoa~t, 1000 Corp. Ctr. Dr. 112008 Monteray Part:, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE DEFICIENCY INFORMATION FOR THIS PAGE: Deficiency Type POC Due Date I SEction Number Type A 06/17/2004 Section Cited 101238(a)1 FACILITY NUMBER: 191200190 VISIT DATE: 06/16/2004 DEFICIENCIES 1 2 3 4 PLAN OF CORRECTIONS(POCs) 1 REPLACE MESH MATERIAL 2 3 4 The backside of the fence to the pony corral was observed to be missing mesh material. A small child was observed on the backside of the corral unknown to staff and could very easily ~rawllwalk 5 into the pony corral 5 7 6 7 6 Type A 06/23/2004 Section Cited 101238(a) 1 The door that Is In the room that will be used as the 2 toddler room was observed to not be Hush with the 3 doorway on the top or on the side. 4 5 6 7 Type A 0€/23/2004 Section Cited 101238(a) 1 There is approxamenHty 1 FOOT 8 inch drop based 1 PROPERLY SECURE AREA. 2 on measurements by LPA, that is directly outside 2 3 the toddler room. 3 4 4 5 5 6 6 7 7 TypeS 07/01/2004 Section Cited 101238(a) 1 The Hoar boards leading from the hallway into the 2 toddler room and the floor boards leading into the 3 toddler room from the preschool room were 4 observed to be loose and In need of repair. This Is (i a potential tripping hazard as well, as there is an 6 opening from the floor to the lip of the floor board 7 that is 1fnch based on measunnents 1 REPAIR OR REPLACE DOOR 2 3 4 5 6 7 1 REPAIR FLOOR BOARDS. PROVIDE COPY OF 2 WORK ORDER UPON COMPLETION 3 4 5 6 7 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: Georgia Brown TELEPHONE: (323)981-3369 LICENSING EVALUATOR NAME: Karen Chambers TELEPHONE: (323)981-3368 LICENSING EVALUATOR SIGNATURE: ***SIGNED*** DATE: 06/16/2004 I acf:nowledge receipt of this form and underetand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: ***SIGNED·- DATE: 06/16/2004 This Notice must be posted for 30 days LIC809 (FAS)~ {06104) Page:2of3 STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FACILITY EVALUATION REPORT (Cont) LA Child Care Eatt, 1000 Corp. Ctr. Dr. #2008 MontenJY Park, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE DEFICIENCY INFORMATION FOR THIS PAGE: Deficiency Type POC Due Date I Section Number FACILITY NUMBER: 191200190 VISIT DATE: 06/16/2004 DEFICIENCIES PLAN OF CORRECTIONS(POCs) Type A 06/16/2004 Section Cited 101152(c)1 · 1 During this visit there were 10 school-age children 2 observed. Facility has been approved for only 4 3 school-age children. 4 5 6 7 1 REDUCE NUMBER OF SCHOOL-AGE CHILDREN 2 3 4 5 6 7 Type A 06/16/2004 Section Cited 101538.2(b) 1 2 3 4 5 6 7 1 THE PROGRAMS ARE TO BE KEPT 2 SEPERATED AT ALL TIMES. 3 4 5 6 7 Type A 06/16/2004 Section Cited 101238(a)1 TypeA · 06/16/2004 Section Cited 10123(g)1 Upon the arrival of the LPA's preschoolers and school-age children were observed playing both Inside and outside commingling. Facility was advised that the children are to be separated and adhere to there activity schedule. Children were later observed corrimlngllng again. 1 On 6/1 0/04 the facility was cited and advised to 1 THOROUGHLY CLEAN FACILITY (TOP TO 2 thoroughly clean facility. During this visit cobwebs 2 BOTTOM) TO INSURE THE OVERALL HEALTH 3 were observed through out the school 3 .AND SAFETY OF THE CHILDREN 4 4 5 5 6 7 1 2 3 4 5 6 7 6 7 There containers of 409, and other- cleaning agents accessible to the children, both ir. the class room as well as to the storag~ area. The lock for the door leading to the storage area was observed to be broken making the room accessible 1 MAKE ANY & ALL TOXINS INACCESSIBLE TO 2 THE CHILDREN. 3 REPAIR LOCK TO STORAGE ROOM 4 5 6 7 Failure to correct the cited deflciency(ies), on or before the Plan of Correction (POC) due date, may result In a civil penalty assessment. SUPERVISOR'S NAME: Georgia Brown TELEPHONE: (323}981-3369 LICENSING EVALUATOR NAME: Karen Chambers TELEPHONE: (323)981-3368 LICENSING EVALUATOR SIGNATURE: ***SIGNED*** DATE: 06/16/2004 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: ***SIGNED ... DATE: 06/16/2004 This Notice must be posted for 30 days UCSG3 (FAS}- (06104) Page: 3 of3 STATE OF CALIFORNIA- HEALTH AND HUMAN SE"RVfCES AGENCY CAUFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNiTY CARE LICENSING DMSION FACILITY EVALUATION REPORT LA Ch!Jd Care East,1000 Corp. Ctr. Dr.#200B Monterey Park, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE ADMINISTRATOR: NIELSON, DEB ERA ADDRESS: 2821 SANTA ROSA CITY: ALTADENA CAPACITY: 34 TYPE OF VISIT: MET WITH: Debra Nielson STATE: CA CENSUS: 18 UNANNOUNCED FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 191200190 850 (818) 798-8083 91001 06/16/2004 03:30PM 06:00PM NARRATIVE 1 2 3 4 5 6 7 A prelicensing visit was made this date by Karen Chambers & Delisa Perez, LPA's, who met with Debra Neilson, Director/Owner. Facility was toured with the assistance of Debra Neilson for the purpose of Inspecting & measuring for a toddler option. During this visit the following was observed and is cited in accordance with Title 22, California Code of Regulations: The overall sanitation of the facility is a concern as toddlers required a more sanitized environment. During this visit the following was discussed In relationship to the toddler option: 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 1. The discipline plan was discussed in relationship to how the 5\'hool will handle biters 2. A copy of a needs and service plan was provided to address potty training 3. A copy of a transition plan was provided as the school needs to address how children will be assessed for transition from the toddler to the preschool SUPERVISOR'S NAME: Georgia Brown TELEPHONE: (323)981-3369 LICENSING EVALUATOR NAME: Karen Chambers TELEPHONE: (323)981-3368 LICENSING EVALUATOR SIGNATURE: ... SIGNED ... DATE: 06/16/2004 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: ***SIGNED ... DATE: 06/16/2004 This report must be available at the facility for public revlew.(3 years). LICaml (FAS)- (08104) Page: 1 of3 STATE OF CALIFORNIA ·HEALTH AND HUMAN SERVICES AGENCY CAUFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSING DIVISION FACILITY EVALUATION REPORT LA Child Care East, 1000 Corp. Ctr. Dr. 112008 Monte FACILITY NAME: CHILDREN'S COUNTRY HOUSE ADMINISTRATOR: NIELSON, DEBERA ADDRESS: 2821 SANTA ROSA CITY: ALTADENA CAPACITY: 34 TYPE OF VISIT: MET WITH: Debra Neilason STATE: CA CENSUS: UNANNOUNCED Park, CA 91754 FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 191200190 850 (818) 798-8083 91001 06/1712004 NARRATIVE 1 2 3 4 An office visit was made this date by Debra Neilson, who attended Comp II. During this visit Ms~ Neilson indicated that she wishes· to withdraw her application for her toddler option & will resubmit at a .later date when the facility is ready. 5 6 7· 8 9 10 11 12 13 14 15 16 17 16 1.9 20 21 22 23 24 25 SUPERVISOR'S NAME: Georgia Brown TELEPHONE: (323)981-3369 LICENSING EVALUATOR NAME: Karen Chambers TELEPHONE: (323)981-3368 LICENSING EVALUATOR SIGNATURE: "**SIGNED ... DATE: 06/17/2004 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: ... SIGNED"** DATE: 06/1712004 This report must be available at the facility for public review (3 years). LIC80.9 (FAS) • (OGJ04) Page: 1 of 1 All POC Have Been Cleared STATE OF CALIFORNIA· HEALTH ~NO HUMAN SERVICES AGENCY CAUFORNIA DEP~RTMENT OF SOCIAL SERVICES CLEARED POC's LA Child Care East,.10DO Corp. Ctr. Dr. #200B COMMUNITY CARE LICENSING DIVISION Monte FACILITY NAME: CHILDREN'S COUNTRY HOUSE POC Due Date I FACILITY NUMBER: VISIT DATE: 07/07/2004 Date Cleared I Comments PLAN OF CORRECTIONS(POCs) Section Number 1 2 07/07/2004 1596.8595(1 )a 3 NOTICE OF SITE VISIT AND REPORTS AND DEEMED 4 NECESSARY ARE TO REMAIN POSTED FOR 30 5 CONSECUTIVIE DAYS. 6 1 08/04/2004 2 Notice was observed to be posted during 3 this visit 4 7 1 Section Cited 2 3 4 5 6 1 2 3 4 7 Section Cited 1 2 3 4 5 6 1 2 3 '4 7 S&ction Cited 1 2 3 4 5 6 .7 Park, CA 91754 1 2 3 4 STATE OF CAUFORNIA· HEAl..TH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAl.. SERVICES COMMUNITY CARE LICENSING DMSION FACILITY EVALUATION REPORT (Cont) LA Child Care East, 1000 Corp. Ctr, Dr. #2008 Montero FACILilY NAME: CHILDREN'S COUNTRY HOUSE DEFICIENCY INFORMATION FOR THIS PAGE: Deficiency Type POC Due Date I Section Number 07/07/2004 Section Cited 1596.8595(1)a Park, CA 91754 FACIUlY NUMBER: 191200190 VISIT DATE: 07/07/2004 DEFICIENCIES PLAN OF CORRECTIONS(POCs) 1 During this visit the posting of the Notice of Site 2 Visit from the 6/10/04 visit was not observed. 3 4 5 6 7 1 NOTICE OF SITE VISIT AND REPORTS AND 2 DEEMED NECESSARY ARE TO REMAIN 3 POSTED FOR 30 CONSECUTIVE DAYS. 4 5 6 7 1 2 3 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 1 2 3 4 5 6 7 4 4 5 6 7 Fallure·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: Georgia Brown TELEPHONE: (323)981-3369 LICENSING EVALUATOR NAME: Karen Chambers TELEPHONE: (323)981-3368 LICENSING EVALUATOR SIGNATURE: ***SIGNED- DATE: 07/07/2004 I acknowledge receipt of this form and understand my· appeal rights as explained and received. FACILilY REPRESENTATIVE SIGNATURE: ... SIGNED"** ucso; (FAS). {0&104) DATE: 07i07/2004 Page: 2 of4 CAUFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DMSION. STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT (Cont) LA Child Cam East, 1GOO Corp. Ctr. Dr.#lOOO Monte FACILITY NAME: CHILDREN'S COUNTRY HOUSE DEFICIENCY INFORMATION FOR THIS PAGE: ·FACILITY NUMBER: 191200190 VISIT DATE: 07/07/2004 - Deficiency Type POC Due Date I Section Number TypeS 07/07/2004 Section Cited H/S1596.8595 Park, CA. 91754 DEFICIENCIES PLAN OF CORRECTIONS(POCs) 1 During this visit the posting of the 6/10/04 Notice of 2 Site visit was not observed posted as required. 3 4 5 6 7 f NOTICE IS TO REMAIN POSTED FOR 30 2 CONSECUTIVE DAYS 3 4 NEW NOTICE POSTED BY LPA 5 6 7 1 2 3 4 5 6 7 1 2 3 4. 5 6 7 ' 1 2 3 4 5 6 7 1 1 2 3 4 5 6 7 1 2 2 3 3 4 5 6 7 4 5 6 7 Failure to correct the cited deficlency(les), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. · SUi'ERVISOR'S NAME: Georgia Brown TELEPHONE: (323)981-3369 LICENSING EVALUATOR NAME: Karen Chambers TELEPHONE: (323)981-3368 LICENSING EVALUATOR SIGNATURE: -SIGNED*** DATE: 07/07/2004 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: -·SIGNED*** LICB(I9 (FAS) ~ [06/04} DATE: 07/07/2004 Page: 4 of 4 STATE OF CALIFORNIA~ HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LlCENSING DIVISION FACILITY EVALUATION REPORT LA Child Care East, 10GO Corp. Ctr. Dr. #2008 Monterey Park, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE DEBERA · ADDRESS: 2821 SANTA ROSA CITY.: ALTADENA CAPACITY: 34 TYPE OF VISIT: MET WITH: Maria Molina ADMINIST~TOR: NIELSON, STATE:CA CENSUS:4 UNANNOUNCED FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 191200190 850 (818) 798-8083 91001 07/07/2004 08:05AM 08:45AM NARRATIVE 1 2 3 A Case Management visit was made this date by Karen Chambers, LPA who met with Marta Molina. This visit was made to insure the the Notice of Site Vis! was still posted from the 6/10/04 visit. During this visit the following was observed and cited in accordance with Title 22, California Code of Regulations: 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME: Georgia Brown TELEPHONE: (323)981-3369 LICENSING EVALUATOR NAME: Karen Chambers TELEPHONE: (323)981-3368 LICENSING EVALUATOR SIGNATURE: ***SIGNED*** DATE: 07/07/2004 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: ·-SIGNED •- DATE: 07/07/2004 This report must be available at the facility for public review (3 years). UCBD9 (FAS) • (G6f04) Page: 1 of4 All POC Have Been Cleared CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COJM.4UNITY CARE LICENSING OMS/ON STATE Of CAUFORNIA- HEALTH AND HUMAN SERVICES AGENCY CLEARED POC's LA Child Care East. 1000 Corp. Ctr. Dr. #200B Montere Paric. CA 91754 FACILITY NUMBER: VISIT DATE: 08/04/2004 FACILITY NAME: CHILDREN'S COUNTRY HOUSE POC Due Date I Section Number 08/06/2004 101238(a) Date Cleared I Comments PLAN OF CORRECTIONS(POCs) 1 2 3 puring this visit.some of the cobwebs were removed. School 4 s to clean top to bottom and maintain a clean and safe 5 ~nvironment, to insure the overall health and safety of the 6 \mlldren. 1 09/22/2004 2 During this visit there were no cobwebs 3 observed 4 7 Section Cited Section Cited Section Cited 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 1 2 3 4 1 2 3 4 STA7E OF CAUFORNIA- HEALTH AND HUMAN SERVICES AGENCY CAUFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSING DIVISION FACILITY EVALUATION REPORT (Cont) f..A Chlld Care E015t, 1000 Corp. Ctr. Cr. #12008 Mont Park, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE DEFICIENCY INFORMATION FOR THIS PAGE: Dollclency Type POC Due Date I Section _NUmber Type A 08/06/2004 Section Cited 101238(a} FACILITY NUMBER: 191200190 VISIT DATE: 08/04/2004 PLAN OF CORRECTIONS(POCs) DEFICIENCIES 1 2 3 4 5 6 7 On 6/1 0/04& 6/16/04 the facility was cited and advised to thoroughly clean facility. Duong this vislt cobwebs were observed through out the school. 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 During this visit some of the cobwebs were removed. School is to clean top to bottom and maintain a dean and safe environment, to insure tlle overall health and safety of the children: 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: Georgia Brown TELEPHONE: (323)981-3369 LICENSING EVALUATOR NAME: Karen Chambers TELEPHONE: (323)981-3368 LICENSING EVALUATOR SIGNATURE: -SIGNED ... DATE: 08/04/2004 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: ... SIGNED ... DATE: 08/04/2004 This Notice must be posted for 30 days UC809 (FAS) • (0Gro4) Page: 2of2 STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CALIFORNiA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DMSION FACILITY EVALUATION REPORT LA Child Care East, 1000 Corp.Ctr. Dr.I200B Monjere Park. CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE ADMINISTRATOR: NIELSON, DEBERA ADDRESS: 2821 SANTA ROSA CITY: ALTADENA CAPACITY: 34 TYPE OF VISIT: MET WITH: Debra Neilson & Betty Johnston STATE:CA CENSUS: 9 UNANNOUNCED FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 191200190 .850 (818) 798-8083 91001 08104/2004 01:15PM NARRATIVE 1 2 3 4 5 6 78 9 ·During the course of a prelicen~ing visit made this date by Karen Chambers and Robert Sanchez, LPA's for the purpose of a toddler option, the following was observed and recited in accordance with Title 22, California Code of Regulations: 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME: Georgia Brown TELEPHONE: (323)981-3369 LICENSING EVALUATOR NAME: Karen Chambers TELEPHONE: (323)981-3366 LICENSING EVALUATOR SIGNATURE: ***SIGNED*** DATE: 08/04/2004 I acknowledge receipt of t~is form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: ***SIGNED *H DATE: 08/04/2004 This report must be available at the facility for public review (3 years). LICOD9 (FAS)- (OSJ04) Page: 1 of2 STATE OF CAUFORNIA ·HEALTH AND HUMAN SERVICES AGENCY CAUFORN!A DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSIN.G DMSION FACILITY EVALUATION REPORT LA Child Care East. 1000 Corp. Ctr. Dr. #2009 Monte:rey Park, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE ADMINISTRATOR: NIELSON, DEBERA ADDRESS: 2821 SANTA ROSA ALTADENA CITY: CAPACITY: 34 TYPE OF VISIT: MET WITH: STATE:CA CENSUS: 9 ANNOUNCED FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 191200190 850 (818) 798-8083 91001 08/04/2004 01:15PM 03:'45 PM NARRATIVE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 A prelicensing site visit was made today to Inspect and measure facility for capacity determination for toddler option program. LPA's Robert Sanchez and Karen Chambers met with Licensee Debera Nielson and Betty Johnston. The following measurements total: -Indoor Space -Toddler room totals 245.31 sq.ft. allowing for 7 toddlers. Sch-Age room totals 427.049 sq.ft. allowing for 12 Sch-Age children. Preschool room totals 382.5 sq.ft. allowing for 10 preschool children. -Outdoor Space - Front Yard for toddlers totals 1791.544 sq.ft. allowing for 23 toddlers The overall capacity-for outdoor play space for all 3 programs is 9452.095 sq.ft. allowing for 126 children -One changing table and one sink . · -Fire Clearance approved for 34 children, 12 of these children may be toddlers ages 18 to 30 months. If licensee is approved for the toddler option program, the current license will change to reflect 29 children, 7 toddlers ages 18 to 30 months and 10 preschoolers ages 2 years until entry into first grade and 12 school age children ages first grade and above. The new total is 29 children. Once all items are completed and approved the licensee may be granted a license for 29 children with aforementioned changes above. · However, the following items are nee9ed before licensure with new changes can be considered. -Staggered time schedule for outside play area between preschool and school age children is needed. -Revised Lie 200 and Lie 500, Discipline policies need to include for toddlers how to handle "biters". -Changing table needs to be secured to table with 2 Inch border around changing mattress. -Outside play yard needs to have sprinkler valves/system barricaded to make inaccesslable to children. -Paint on outside of building is chipping, this Is accessiable to children. -The outside play ground for toddlers is uneven and there are three areas were there are drops of6 inches or greater and tree trucks exposed above ground, 12 inches or higHer. Some concrete slab Is elevated and cracked. This issue will be discussed with management for evaluation & reCommendations. Due date for correction 8/18/04. An exit interview was completed regarding this visit. SUPERVISOR'S NAME: Miguel Villegas TELEPHONE: (323) 981-3350 LICENSING EVALUATOR NAME: Robert Sanchez TELEPHONE: (323) 981-3350 LICENSING EVALUATOR SIGNATURE: ... SIGNED*** DATE: 08/04/2004 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: ***SIGNED ... DATE: 08/04/2004 This report must be available at the facility for public review (3 years). LICBO!! (FAS) • (OGJ04) Page: 1 of 1 STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY CAUFORNtA DEPARTMENT OF SOCIAL SERVlCE;S COMMUNITY CARE LICENSING DIVISION FACILITY EVALUATION REPORT LA Child Care East, 1000 Corp, Ctr. Dr.#200B Monterey Park, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE ADMINISTRATOR: NIELSON, DEBERA ADDRESS: 2821 SANTA ROSA ALTADENA CITY: CAPACITY: 34 TYPE OF VISIT: MET WITH: Debra Neilson FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: STATE:CA DATE: CENSUS: 11 UNANNOUNCED TIME BEGAN: TIME COMPLETED: 191200190 850 (818) 798-8083 91001 09/22/2004 02:00PM NARRATIVE 1 2 3 4 5 6 7 During the course of a prelicensing visit made this date by Karen Chambers & Robert Sanchez; LPA's a plan of correction visit was made. During this visit the following items were found to be corrected in accordance with Title 22 California Code of Regulations: SEE ATTACHED REPORT 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME: Georgia Brown TELEPHONE: (323)981-3369 LICENSING EVALUATOR NAME: Karen Chambers TELEPHONE: (323)981-3368 LICENSING EVALUATOR SIGNATURE: .... SIGNED .... DATE: 09/22/2004 I acknowledge receipt of this form a.nd understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: .... SIGNED .... DATE: 09/22/2004 This report must be available at the facility for public review (3 years). LIC80S (FAS} • (06J0.4) Page: 1 of 1 STATE OF CAUFORNIA· HEALTH AND HUMAN SERVICES AGENCY CAUFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSING OMSION FACILITY EVALUATION REPORT LA Child Cara East.1000 Corp. Ctr. Dr. 112008 Monterey Park, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE ADMINISTRATOR: NIELSON, DEBERA ADDRESS: 2821 SANTA ROSA CITY: ALTADENA CAPACITY: 34 TYPE OF VISIT: MET WITH: Debera Nielson STATE:CA CENSUS: 11 ANNOUNCED FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 191200190 850 (818) 798-8083 91001 09/22/2004 02:00PM 03:30PM NARRATIVE 1 2 3 A prelicensing follow up site visit was conducted today by LPA's Karen Chambers & Robert Sanchez. The LPA's met with Licensee Debera Nielson. · The purpose of today's visit was to review corrections requested from the 8/4/04 site visn. 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 ·19 20 21 22 During this visit the LPA's reviewed the documents that needed revisions and observed the indoor and outdoor areas. The following documents have been submitted and are complete: -The staggered schedule of activities between programs -Lie 200, Lie 500, discipline policies for toddlers, sprinkler valves have been covered made inaccessiable to children, outside of building has been painted. -The cracked concrete slab has been recemented and evened-out. The following items still need correction: -Changing table is "shakey' not stable and needs to be secured to wall. In addition, the changing mattress needs velcro underneath plastic cushion. -The licensee has decelded to barricade the large tree and place a fence around the entire tree covering all roots that are above ground and exposed. -The licensee will have to install a fence/barricade all around patio in front of entrance way to facility. -The licensee needs to cover the brick ~ower bed with cushioned absorpent material. This flower bed is made up of bricks that have rough edges that point out. Due date for correction is 10/6/04. An exit interview was conducted today regarding this visit. 23 24 25 SUPERVISOR'S NAME: Miguel Villegas TELEPHONE: {323) 981-3350 LICENSING EVALUATOR NAME: Robert Sanchez TELEPHONE: (323) 981-3439 LICENSING EVALUATOR SIGNATURE: *'*SIGNED- DATE: 09/22/2004 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: -SIGNED- DATE: 09/22/2004 This report must be available at the facility for public review (3 years). LICBD9 (FAS}- (06104) Pa_ge: 1 of1 STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY CAUFORNIA. DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSING DIVISION FACILITY EVALUATION REPORT LA Child Care East, 1000 Corp. Ctr. Dr. M2GOB Monterey Park, CA 91754 M FACILITY NAME: CHILDREN'S COUNTRY HOUSE ADMINISTRATOR: NIELSON, DEBERA ADDRESS: 2821 SANTA ROSA CiTY: ALTADENA CAPACITY: 34 TYPE OF VISIT: MET WITH: Debra Nielson STATE:CA CENSUS: ANNOUNCED FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 191200190 850 (818) 798-8083 91001 11/04/2004 04:03PM NARRATIVE 1 This report is a follow up to our telephone conversation today. 2 3 4 5· 6 7 In the original report, it was agreed upon that you would install a fence/barricade around the patio In front of entrance which would provide a safe environment for toddlers in that area. You are now indicating that you do not desire to fence/barricade your patio. Any alienate methods of correction will have to be inspected by our department prior to licensure, to ensure the health and safety of children. 8 9 10 11 12 13 14 15 Please contact Licensing Unit Manager Jose Delgado at 323 981-3350 to Jet him know when your corrections are completed and ready for follow up inspection. This report is to inform you that all the corrections that are pending from 9/22/04 report will be inspected at facility once completed. *This report was mailed 11/3/04 for Licensee' signature. 16 17 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME: Miguel Villegas TELEPHONE: (323) 9!3.1-3350 LICENSING EVALUATOR NAME: Robert Sanchez TELEPHONE: (323) 981-3439 LICENSING EVALUATOR SIGNATURE: ... SIGNED ... DATE: 11/04/2004 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: -SIGNED ... DATE: 11/04/2004 This report must be available at the facility for public review (3 years). ucaos (FASI- (06104) Page: 1 of1 STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSING DMSION FACILITY EVALUATION REPORT"(Cont) LA Child Care East, 1000 Corp.Ctr.Dr., #2008 Montere Park, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE DEFICIENCY INFORMATION FOR THIS PAGE: Doflciency Type POC Due Date I FACILITY NUMBER: 191200190 VISIT DATE: 12/03/2004 DEFICIENCIES PLAN OF CORRECTiONS(POCs) Section Number Type A 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 4 5 6 7 1 2 3 4 5 6 7 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 1 1 2 3 4 5 6 7 Failure to correct the cited deflciency(ies), on or before the Pian of Correction (POC) due date, may result in a civil penalty assessment. SUPERVISOR'S NAME: Lois Petzold TELEPHONE: (323) 981-3350 LICENSING EVALUATOR NAME: Miguel Villegas TELEPHONE: {323) 981-3350 LICENSING EVALUATOR SIGNATURE: H* SIGNED- DATE: 12/03/2004 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: -SIGNED- DATE: 12/03/2004 This Notice must be posted for 30 days UCBOO (FAS) • (00104) Page: 2 of 1 STATE OF CALIFORNIA~ HEALTH AND HUMAN SERVICES AGENCY CAI.IFQRN!A DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSING DIVJSION FACILITY EVALUATION REPORT LA Child Care East. 1000 Corp. Ctr. Dr., #2008 Monte Pari!, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE ADMINISTRATOR: NIELSON, DEBERA ADDRES.S: 2821 SANTA ROSA CITY: ALTADENA CAPACITY: 34 TYPE OF VISIT: MET WITH: FACILITY NUMBER: FACILITY TYPE: TELEPHONE: STATE: CA ZIP CODE: CENSUS: DATE: UNANNOUNCED TIME BEGAN: TIME COMPLETED: 191200190 . 850 (818) 798·8083 91001 12/03/2004 08:22AM NARRATIVE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME: Lois Petzold TELEPHONE: (323) 981·3350 LICENSING EVALUATOR NAME: Miguel Villegas TELEPHONE: (323) 981-3350 LICENSING EVALUATOR SIGNATURE: ***SIGNED*** DATE: 12/03/2004 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: ***SIGNED*** DATE: 12/03/2004 This report must be available at the facility for public review (3 years). LIC805 (FAS)- (06J04) Page: 1 of 1 All POC Have Been Cleared STATE OF CALIFORNIA~ HEALTH AND HUMAN SEJtVJCES AGENCY CAUFORNIA DEPARTMENT OF Sc;lCIAL SERVICES COMMUNITY C.;RE LICENSING DIVISION CLEARED POC's LA Chlkl care East. 1000 Corp. ctr. or.t200B Mgnterey Pal1c, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE POC Due Date I SGcfion Number 04/05/2005 102238(a) FACILITY NUMBER: VISIT DATE: 03/28/2005 Date Cleared I Comments PLAN OF CORRECTIONS(POCs) 1 2 3 04/12/2005 . 4 nsure that any & all openings are secured so that a child can 5 hot stick or poke their hand· inside 6 1 Openings were observed to have been 2 secured. 3 4 Pictures taken 7 Section Cited Section Cited 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 1 2 3 4 1 Section Cited 2 3 4 5 6 7 1 2 3 4 STA'l'E OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CAL1FORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNm' CARE L-ICENSING DMS10N FACILITY EVALUATION REPORT (Cont) LA Child Care East, 1000 Corp. Ctr. Dr. tr.!OOB Monterey Part, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE DEFICIENCY INFORMATION FOR THiS PAGE: Deficiency Type POC Due Date I FACILITY NUMBER: 191200190 VISIT DATE: 03/28/2005 DEFICIENCIES PLAN OF CORRECTIONS(POCs) Section Number Type A 04/05/2005 Section Cited 10223B(a) 1 There is an opening between tne gate and the 2 fence. The opening is such that a child can stick 3 their hand inside where the goat is housed. 4 5 6 7 1 Insure that any & all openings are secured so that 2 a child can not stick or poke their hand Inside 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 1 2 3 4 5 6 7 1 2 3 4 4 5 6 5 6 7 7 Failure to correct the cited deflclency(les), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment SUPERVISOR'S NAME: Georgia Brown TELEPHONE: (323}981·3369 LICENSING EVALUATOR NAME: Karen Chambers TELEPHONE: (323)981·3368 LICENSING EVALUATOR SIGNATURE: ••• SIGNED*'* DATE: 03/28/2005 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: ... SIGNED*** DATE: 03/28/2005 This Notice must be posted for 30 days l1C809 (FAS)- (06/04) Page: 2of2 STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DMSION FACILITY EVALUATION REPORT LA Child Care Eaat,1000 Corp. Ctr. Dr. #2009 Monterey Park, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE ADMINISTRATOR: NIELSON, DEB ERA ADDRESS: 2821 SANTA ROSA CITY: ALTADENA CAPACITY: 34 TYPE OF VISIT: MET WITH: Debra Nielson FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: STATE:CA DATE: CENSUS:B UNANNOUNCED TIME BEGAN: TIME COMPLETED: 191200190 . 850 (818). 798-8083 91001 03/28/2005 02:15PM 02:45PM NARRATIVE 1 2 A plan of correction visit was made this date by Karen Chambers, LPA. During this visit the following item was observed and cited in accordance with Title 22, California Code of Regulations. 3 4 5 6 7 8 During this visit the following items were ·observed to be corrected in accordance with Title 22, California Code of Regulations: 9 10 11 12 13 14 15 SEE ATTACHED REPORT 16 17 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME: Georgia Brown TELEPHONE: (323)981-3369 LICENSING EVALUATOR NAME: Karen Chambers TELEPHONE: (323)981-3368 LICENSING EVALUATOR SIGNATURE: -SIGNED*** DATE: 03/28/2005 I acknowledge receipt of this forin and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: ... SIGNED ... DATE: 03/28/2005 This report must be available at the facility for public review (3 years). UCBr•9 (FAS)- (OS/04} Page: 1 of2 STATE OF CALIFORNIA~ HEALTH AND HUMAN SEP.VICES AGENCY CAUFORHIA DEPARTMENT OF SOCfAL SERVICES COMMUNITY CARE UCENSING DMSJON- FACILITY EVALUATION REPORT (Cont) LA Ch.lld Gam East, 1000 Corp. Ctr. Dr. #.200B Monterey P.aril:, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE DEFICIENCY INFORMATION FOR THIS PAGE: Deficiency Typo POC Due Date I FACILITY NUMBER: 191200190 VISIT DATE: 04/12/2005 PLAN OF CORRECTIONS(POCs) DEFICIENCIES Section Number Type A 04/12/2005 Section Cited 101238(a)1 1 2 3 4 5 6 7 During this visit there was no hay observed In the horse corral to absorb any of the horse's waste. During this visit this LPA was attacked by flies as there was waste observed in the corral. Pictures taken 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 1· 2 3 4 5 6 7 4 5 6 7 The licensee shall take measures to keep the center free of flies, other insects, and rodents. During visit hay was placed In corral. Ucensee is to insure that at all times there is an amble amount of hay to absorb the horses waste and reduce flies Failure to correct the cited deficlency(les), on or before the Plan of Correction (POC) due date, may result In · a civil penalty assessment. SUPERVISOR'S NAME: Georgia Brown TELEPHONE: (323)981-3369 LICENSING EVALUATOR NAME: Karen Chambers TELEPHONE: (323)981-3368 LICENSING EVALUATOR SIGNATURE: -·SIGNED_. DATE: 04/1212005 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: -*SIGNED*** DATE: 04/1212005 This Notice must be posted for 30 days LICB09 (FAS}- {06104) Page: 2 of 1 STAT~ OF CALIFORNIA~ HEALTH AND HUMAN SERVICS:S AGENCY CAUFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DMSION FACILITY EVALUATION REPORT LA Child Care East,1000 Corp. Ctr. Dr.I#200B Park, CA 91754 Mont FACILITY NAME: CHILDREN'S COUNTRY HOUSE ADMINISTRATOR: NIELSON, DEB ERA ADDRESS: 2821 SANTA ROSA CITY: ALTADENA CAPACITY: 34 TYPE OF VISIT: MET WITH: Debra Nielson FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: STATE:CA DATE: CENSUS: 8 UNANNOUNCED TIME BEGAN: TIME COMPLETED: 191200190 850 (818) 798-8083 91001 . 04/12/2005 01;15 PM NARRATIVE 1 2 A plan of correction visit was made this date by Karen Chambers, LPA. During this visit the following was observed and cited in accordance with Title 22, California Code of Regulations: 3 4 5 During this visit the following was observed to be corrected; 6 7 SEE ATTACHED REPORT 8 9 10 11 12 13 14 15 16 17 18 19 20 21 I 22 23 24 25 SUPERVISOR'S NAME: Georgia Brown TELEPHONE: (323)981-3369 LICENSING EVALUATOR NAME: Karen Chambers TELEPHONE: (323)981-3368 LICENSING EVALUATOR SIGNATURE: ***SIGNED ••• DATE: 04/12/2005 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: ***SIGNED*** DATE: 04/12/2005 This report must be available at the facility for public review (3 years). ucsoa (FAS} ~ (061041 Page: 1 of 1 Control Number33-CC-20060109104728 STAlE Of CALlFORNLA • HEALnt tal HUMAN sa:tV~CES AGENCY CAUFORMA DEPARTMENT OF SOCIAL HRVJCES COMMUNJTY CARE UCBISING onnstON LA Chid Can! Euf.11HXJ Corp. Ctr. Dr. ti!200B COMPLAINT INVESTIGATION REPORT (Cont) -Pari<,CA111.. FACILITY NAME: CHILDREN'S COUNTRY HOUSE DEFICIENCY INFORMATION FOR THIS PAGE: Deficioucy 1'ypa POC Due Dalll/ Section NlRIIber DEFICIENCIES Type A 1 01/1712006 SeclionCitad 101239(m)(n) 2 PLAN OF CORRECTIONS(POCs) The outdoor play equipment was observed to efther be dlrty, missing par1s or loose. 3 4 5 6 7 SactionCitad VISIT DATe: 01/11/2006 There were toys Inside of the classroom that was observed to either be This report must be available at Child Care and Group Home facilities for public review for 3 years. LICaO!< (FAS) • (05104) Page: 1 of2 All POC Have Been Cleared STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CAUFORNJA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DMSION CLEARED DEFICIENCIES LA Child Care East, 1000 Corp. Ctr Dr 2008 Monterey, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE FACILITY NUMBER: 191200190 VISIT DATE: 09/30/2008 POC Due Date I Section Number 10/01/2008 101238.3(b) Section Cited Date Cleared I Comments PLAN OF CORRECTIONS(POCs) 1 ~ Licensee agrees to find a means to ensure that the bathroom 4 s kept maintained and cleaned en a daily basis in a manner 5 hat is conducive to the Health and Safety of children receiving care in the facility. 6 7 1 2 3 4 5 6 10106/2008 1 Cleared By Visit. LPA's Zaragoza and 2 Dumo!t observed that the bathroom was 3 clean and maintained. Licensee is cleaning the bathroom with a bleach 4 cleaning solution. 1 2 3 4 7 Section Cited 1 2 3 4 5 6 7 1 2 3 4 1 Section Cited 2 3 4 5 6 7 1 2 3 4 Control Number 33-CC-20070413114327 CAUFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DMstON STATE OF CAUFORNIA- HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont) LA Chlfd Cato Eaat, 1001) Corp. Ctr Dr ZOOB Monterey, CA Dt754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE " DEFICIENCY INFORMATION FOR THIS PAGE: Doflclency Type POC Duo Date/ Section Number Type A 04/20/2007 Section Cited 101216.3(b) Type A 04/20/2007 Section Cited 101216.1 (c) FACILITY NUMBER: 191200190 VISIT DATE: 04/18/2007 DEFICIENCIES 1 2 3 4 PLAN OF CORRECTIONS(POCs) TEACHER-CHILD RATIO. LPA observed teaching transcripts and was able to verify qualifications for lwo teaching staff in the facility today. Two other staff members were also present. One of these 5 staff did not have proof of teaching qualifications. 6 Another teacher subsequently arrived to this site at 7 11:45 A.M. and appropriate ratios were restored. 1 Please submit a written plan to the Department 2 outlining what steps shall be taken to ensure there 3 is qualified staff on the premises to meet 4 appropriate teacher-child ratios at all times durtng 5 hours of operation as this will further ensure the 6 Health and Safety of children In care. 7 TEACHER QUALIFICATIONS AND DUTIES. PA observed teaching transcripts and was able to verify qualifications for two teaching staff in the facility today. One of these staff did not have proof of teaching qualifications during this site visit However, another teacher subsequentiy arrived to this site at11 :45 A.M. and qualified staff was on site to meet requirements for clients served. 1 Please submit a written plan to the Department outlining what steps shall be taken to ensure there 2 3 Is qualified staff on the premises to meet 4 appropriate teacher-child ratios at all times during 5 hours of operation as this will further ensure the 6 Health end Safety of children in care. 1 2 3 4 5 6 7 7 1 1 2 3 3 4 5 4 5 6 7 6 7 1 2 3 4 5 6 7 1 2 3 4 2 5 6 7 Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result In a ci\11 penalty assessment. SUPERVISOR'S NAME: Knute Martin TELEPHONE: (323) 981-3365 LICENSING EVALUATOR NAME: Paul Zaragosa TELEPHONE: (323) 981-3371 u~;r~~{"\{' DATE: 04/18/2007 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2007 This Notice must be posted for 30 days STATS OF CAUFORNIA ·HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSING DMSlON LA Child Care East. 1000Corp. CtrDr200B Monterey,CA 91754 This is an official report of an unannounced visiUinvestigation of a complaint received in our office on 04/13/2007 and conducted by Evaluator Paul Zaragosa PUBLIC COMPLAINT CONTROL NUMBER: 33-CC-20070413114327 FACILITY NAME: CHILDREN'S COUNTRY HOUSE ADMINISTRATOR: NIELSON, DEBERA 2821 SANTA ROSA ADDRESS: CITY: ALTADENA CAPACITY: 34 MET WITH: Debra Nielson FACILITY NUMBER: FACILITY TYPE: TELEPHONE: STATE: ZIP CODE: CENSUS: 31 DATE: UNANNOUNCED TIME VISIT BEGAN: TIME COMPLETED: 191200190 850 (818) 798-8083 91001 04/18/2007 11:15AM 12:30 I"M ALLEGATION($): 1 1). Teacher-Child Ratios not met. 2 2). Teacher is not qualified. 3 4 5 6 7 8 9 INVESTIGATION FINDINGS: 1 Licensing Program Analyst Zaragoza met with Director, Debra Nielson, to discuss the above referenced 2 allegations. 3 4 5 6 LPA initially observed (4) staff members on site today. Transcripts were reviewed for each staff member present. LPA Zaragoza was able to verify teaching qualifications for two of these staff members supervising children. 7 8 9 Transcripts were also reviewed and verified for another teacher who subsequently arrived to this program. 10 The following deficiencies were observed in accordance with Title 22 Regulation for Child Care Centers as 11 indicted on the page that follows. 12 13 An exit interview was conducted and LPA also presented an Appeal Ri hts form (LIC 9058). Substantiated Estimated Days of Completion: SUPERVISOR'S NAME: Knute Martin TELEPHONE: (323) 981-3365 LICENSING EVALUATOR NAME: Paul Zaragosa TELEPHONE: (323) 981-3371 LICENSING EVALUATOR SIGNATURE: 17~~~~- DATE: 04/18/2007 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: ([)A 1.. ()~ 1/J DATE: 04/18/2007 This report must be available at Child Care and Group Home facilities for public review for 3 years. UC9(199 {FAS) ~(06/04) Page: 1 of2 STATE OF CAl.IFORNIA. HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DMS!ON CCLD Regional Office 1000 CORPORATE CNTR DR. 200-B MONTEREY PARK, CA 91754 04/15/2011 CHILDREN'S COUNTRY HOUSE 191200190 3835 LANDFAIR ROAD PASADENA, CA 91107 Letter of Deficiency Citations Cleared Dear LiCensee. The following deficiencies, initially cited during a visit on 10/19/2007, have been cleared: Section Cited: 191238.2(e} Date Due: 11/02/2007 Plan of Correction: Corrections: Clearance Date: Licensee agrees to replenish theses areas with additional sand and/or other appropriate cushioning materials. Licensee has subnitted a receipt to demonstrate additional sand has been purchased In an effort to replenish cushioning materials. 10/20/2007 Seetion Cited: 101226(e} Date Due: 11/02/2007 Plan of Correction: Licensee agrees to submit a written plan to the Department outlln!ng what steps shall be taken to ensure that medications are labelled pro-~rly and dated as well as this further ensures the Health and Saf:lty og Children receiving care In the facility. Corrections: Clearance Date: Licensee has submitted a statement certifying that she will ensure all medicines for children are current. dated, and named. 10/20/2007 LiCENSING EVALUATOR NAME: Paul Zaragosa u'":P~.,o~y TELEPHONE: (323} 219·5525 DATE: 04/15/2011 This report must be available at Child Care and Group Home facilities for public review for 3 years. Cleared POC Letter (FAS)- (04105) Page: 1 of 1 All POC Have Been Cleared STATE OF CAUFORNIA ·HEALTH AND HUMAN SERVI!:ES AGENCY CLEARED DEFICIENCIES CAUFORNIA DEPARTMEPfT OF SOCIAL SERVICES COMMUNITY CARE UCENSING DMSION CCLO Regional Office,1000 CORPORATE CNTR DR. 200-B MONTEREY PARK, CA 9175-4 FACILITY NAME: CHILDREN'S COUNTRY HOUSE FACILITY NUMBER: 191200190 VISIT DATE: 10/19/2007 POC Due Date I Section Number 11/02/2007 191238.2(.) Date Cleared I Comments PLAN OF CORRECTIONSJPOCs) 1 2 10/20/2007 1 Licensee agrees to replenish theses areas with additional sand 2 3 5 ~nd/or other appropriate cushioning materials. 4 ! 6 7 11/02/2007 Section Cited 101226(e) 1 2 3 icensee agrees to submit a written plan to the Department outlining what steps shall be taken to ensure that medications 4 5 ~re labelled properly and dated as well as this further ensures the Health and Safety og Children receiving care in the facility. 6 10/20/2007 1 Licensee has submitted a statement 2 certifying that she will ensure all 3 medicines for children are current, dated, 4 and named. 7 Section Cited 1 2 3 4 5 6 7 Section Cited 1 2 3 4 5 6 7 Licensee has subnltted a receipt to demonstrate additional sand has been purchased in an effort to replenish cushioning materials. 1 2 3 4 1 2 3 4 STAT:= CF CAUFORNIA- HEAl.TH AND HUMAN SERVICES AGENCY CAUFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSlNG DMSION FACILITY EVALUATION REPORT (Cont) LA Child Care East, 1000 Corp. Ctr Or 2008 Monterey, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE DEFICIENCY INFORMATION FOR THIS PAGE: Doflcloncy Type POC Due Date/ FACILITY NUMBER: 191200190 VISIT DATE: 10/19/2007 DEFICIENCIES PLAN OF CORRECTIONS(POCs) TypeB 11/02/2007 Section Cited ',91238.2(e) 1 OUTDOOR ACTIVITY SPACE. LPA Zaragoza 2 toured the outdoor play area and observed that 3 sand levels are low and compressed at the base of 4 the slide and metal climbing apparatus located on 5 the main yard. 6 7 1 Licensee agrees to replenish theses areas with 2 additional sand and/or other appropriate cushioning 3 materials. 4 5 6 7 TypeB 11/0212007 Section Cited 101226(e) 1 2 3 4 5 6 7 1 Licensee agrees to submit a written plan to the 2 Departmenl outlining what steps shall be taken to 3 ensure that medications are labelled properly and Section Number HEALTH RELATED SERVICES. LPA observed stored medications and found a bottle of children's motrin that expired: 04/07. Also, a boltle of Banzaline DM which expired: 08/07. Theses medications were expired and were noted to be missing the child's name and/or date medication was brought In to this facility. 1 2 3 4. 5 6 7 1 2 3 4 5 6 7 4 dated as well as this further ensures the Health and 5 Safety og Children receiving care in the facility. 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 Failure to correct the coted deficiency{les), on or before the Plan of Correction (POC) due date, may result on a civil penalty assessment. SUPERVISOR'S NAME: Knute Martin TELEPHONE: (323) 981-3365 LICENSING EVALUATOR NAME: Paul Zaragosa TELEPHONE: (323) 981-3371 LICENSING EVALUATOR SIGNATURE: ?~~ DATE: 10/19/2007 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: Aa~/h n/74/~ LICBOf (FAS) • (06104) DATE: 10/19/2007 Page: 3 of 3 STATE OF CAUFORNIA • HEAl.Ttl AND HUMAN SERVICES AGENCY CAUFORNIA DEPARTMENT OF SOClAt SERVlCES COMMUNITY CARE UCENSING DMSION FACILITY EVALUATION REPORT (Cont) FACILITY NAME: CHILDREN'S COUNTRY HOUSE LA Child CBI'll East,1000 Co1p. Ctr Dr2DOB Monterey, CA 91754 FACILITY NUMBER: 191200190 VISIT DATE: 10/19/2007 NARRATIVE 1 2 3 4 5 6 7 8 9 Staff and children records were reviewed for completeness including but not limited to Criminal Record Clearances for aduns, Director Qualifications and verification of CPR/First Aid and health preventative practices documentation. Review of required forms was made. A review of all facility staff or other individuals who require caregiver background checks was conducted on this date to determine if they have received criminal record and child abuse index clearances or exemptions and/or have provided proof of submission of finger prints to DOJ, FBI and CAlC. MOST RECENT EXEMPTION REGULATIONS DISCUSSED. 10 11 12 13 14 15 16 17 18 19 20 21 INTERNET ADDRESS: http://www.ccld.ca.gov- To access licensing forms, updates and Title 22. After a complete inspection of the facility, the following deficiencies were observed in accordance with California Code of Regulations Title 22 Division 12 during today's visit as indicated on the page that follows. An exit interview was conducted and an Appeal Rights form (LIC 9058) was also presented. 22 23 24 25 26 27 28 29 30 31 32 SUPERVISOR'S NAME: Knute Martin TELEPHONE: (323) 981-3365 LICENSING EVALUATOR NAME: Paul Zaragosa TELEPHONE: (323) 981-3371 LICENSING EVALUATOR SIGNATURE: f~ ~~i DATE: 10/19/2007 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: xaJ~/h~L--l.1CB09 (FAS} • (08104) DATE: 10/19/2007 Page: 2 of 3 STATE CF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DtVISION FACILITY EVALUATION REPORT LA Clllld Cam East, 1000 Corp, Ctr Dr 2008 Monterey, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE ADMINISTRATOR: NIELSON, DEB ERA ADDRESS: . 2821 SANTA ROSA ALTADENA CITY: 34 CAPACITY: TYPE OF VISIT: Required· 5 Year MET WITH: Debera Nielson STATE:CA CENSUS: 25 UNANNOUNCED FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 191200190 8·5o (818) 798-8083 91001 10119/2007 02:30PM 04:15PM NARRATIVE 1 2 3 An Annual Site visit was conducted on this. date by Licensing Program Analyst's Zaragoza and Spiller. A complete tour of the facility was conducted. 4 5 6 7 8 9 Rooms identified on facility sketch were inspected Furniture and equipment were inspected for age appropriateness and good repair. Telephone service, heating, lighting and ventilation were evaluated. Napping equipment and bedding were inspected. Storage for children's belongings and an isolation area with a sink, toilet, and mats/cots was inspected. Age appropriate sinks and toilets were inspected for availability and good repair. General sanitation was observed. Availability of indoor drinking water was observed. 10 11 12 13 14 15 16 17 18 19 20 21 22 231 24 I 25 Outdoor play takes place on an adjacent outdoor play space. Outdoor equipment was inspected for safety, cushioning material, good repair and age appropriateness. Required shade, drinking water and fencing were inspected. Play area was inspected for hazards and inaccessibility to bodies of water. Snack/lunch menus were reviewed. Food and snacks were reviewed for availability, quantity and appropriateness to children in care. Food preparation areas were toured for safety, cleanliness. A review of cleaning and food supply storage areas was made. First Aid supplies were inventoried. Please contact your analyst for regulations If considering using Nebulizer or administering Blood-Glucose testing. Teacher child ratios were observed and staff names recorded. Care and supervision was evaluated to determine if the basic needs of children are met. SUPERVISOR'S NAME: Knute Martin TELEPHONE: (323) 981-3365 LICENSING EVALUATOR NAME: Paul Zaragosa TELEPHONE: (323) 981-3371 LICENSING EVALUATOR SIGNATURE: ~~ DATE: 1011912007 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2007 This report must be available at Child Care and Group Home facilities for public review for 3 years. L!CBD9 (FAS) • (06104) Page: 1 of3 Control Number 33-CC-200809291 03011 STATE OF CAUFORNIA~ HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSING DMSION COMPLAINT INVESTIGATION REPORT (Cont) LA Cl11kl Care East, 1000 Corp. CtrDr 2008 Montl:lrey, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE FACILITY NUMBER: 191200190 VISIT DATE: 09/30/2008 NARRATIVE 1 2 3 4 5 6 7 8 9 After a tour of the center, the following deficiency is cited in accordance with Title 22, Division 12, of Child Care Centers as indicated on the page that follows. An exit interview was conducted and LPA also presented an Appeal Rights form (LIC 9058). 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 SUPERVISOR'S NAME: Knute Martin TELEPHONE: (323) 981-3365 LICENSING EVALUATOR NAME: Paul Zaragosa TELEPHONE: (323) 219-5525 ""'i)~"'?{t~" DATE: 09/30/2008 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2008 UC9099 {FAS) ~ {06/04) Page: 2 of3 STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CAUFORNJA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CAR£ UCENSING DIVISION COMPLAINT INVESTIGATION REPORT lA Child Care East, 1000 Corp. Ctr Dr 2008 Monterey, CA 91754 This is an official report of an unannounced visit/investigation of a complaint received in our office on 09/29/2008 and conducted by Evaluator Paul Zaragosa PUBLIC COMPLAINT CONTROL NUMBER: 33-CC-20080929103011 FACILITY NAME: CHILDREN'S COUNTRY HOUSE ADMINISTRATOR: NIELSON, DEB ERA ADDRESS: 2821 SANTA ROSA CITY: ALTADENA CAPACITY: 34 STATE: CENSUS: UNANNOUNCED MET WITH: Camille Robinson FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: 191200190 850 (818) 798-8083 91001 09/30/2008 12:30 PM 02:00PM ALLEGATION(S): 1 1). Physical Plant-backed up sewer system affecting sink and toilet. 2 3 4 5 6 7 8 9 INVESTIGATION FINDINGS: 1 Licensing Program Analyst Zaragoza met with teacher, Camille Robinson, to discuss the above referenced 2 allegation. 3 4 Ms. Robinson stated that she began to notice that last Thursday, she noticed that a toilet was flushing very 5 slowly. The toilet is located to the left, by the entrance, in the only bathroom where two toilets are located. On 6 Friday, the toilet located on the left-side completely stopped working and began to overflow. There is also a 7 kitchen with dual sinks. When the toilet began to overflow, the sink on the right-hand side concurrently began to 8 · back-up. Ms. Robinson stated that the sink backed up 114". 9 10 11 12 13 Ms. Robinson stated the overflow of water did not run Into the classroom. Ms. Robinson also stated the kitchen sink did not overflow. Ms. Robinson had the kitchen sink repaired 09/27108 and the toilet was assessed. Substantiated SUPERVISOR'S NAME: Knute Martin Estimated Days of Completion: TELEPHONE: {323) 981-3365 LICENSING EVALUATOR NAME: Paul Zaragosa TELEPHONE: (323) 219-5525 LICENSING EVALUATOR SIGNATURE: ~~~A DATE: 09/30/2008 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 09130/2008 This report must be available at Child Care and Group Home facilities for public review for 3 ysars. LIC9G99 (FAS} • (Oti/04) Page: 1 of 3 STATE OF CAUFORNIA- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERViCES COMMUNITY CARE LICENSING DIVISION LA Child Care East 1000 Corp. Ctr Dr 2008 Monterey, CA 91754 10/06/2008 CHILDREN'S COUNTRY HOUSE 191200190 3835 LANDFAIR ROAD PASADENA, CA 91107 Letter of Deficiency Citations Cleared Dear Licensee, Tha following deficiencies, initially ctted during a visit on 09/30/2008, have been cleared: Section Cited: 1 01239(e)(4) Plan of Correction: Licensee agrees to have thls toilet repaired as this shall further ens1..1re the Health and Safety of children receMng care in the facl!lty. Date Due: 10/06/2008 Corrections: Cleared By Visit. LPA's Zaragoza and Clearance Date: 10/06/2008 Dumolt observed that this toilet has been repired. LICENSING EVALUATOR NAME: Paul Zaragosa TELEPHONE: (323) 219-5525 LICENSING EVALUATOR SIGNATURE: v~~~~~ DATE: 10/06/2008 This report must be available at Child Care and Group Home facilities for public review for 3 years. Cloered POC Lettor{FAS)- (04105) Pago: 1 of1 All POC Have Been Cleared STATE OF CALIFORNIA -HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVJCES COMMUNITY CARE LICENSING DIVISION CLEARED DEFICIENCIES LA Child Care East, 1DOO Corp. Ctr Dr 2008 MontD111y, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE FACILITY NUMBER: 191200190 VISIT DATE: 09/30/2008 POC Due Date I Section Number 10/06/2008 101239(0)(4) Date Cleared I Comments PLAN OF CORRECTIONS(POCs) 1 2 1 5 facility. 6 7 4 repired. 1 Section Cited 2 3 4 5 6 7 1 2 3 4 1 Section Cited 2 3 4 5 6 7 Section Cited 10/0612008 3 [licensee agrees to have this toilet repaired as this shall further 2 Cleared By Visit. LPA's Zaragoza and 4 ~nsure the Health and Safety of children receiving care in the 3 Dumolt obseiVed that this toilet has been 1 2 3 4 5 6 7 1 2 3 4 1 2 3 4 STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY CAUFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSING DMSION COMPLAINT INVESTIGATION REPORT (Cont) U ChUd Cal8 East, 1000 Corp. Cb" Dr 2008 Monterey, CA91764 FACILITY NAME: CHILDREN'S COUNTRY HOUSE DEFICIENCY INFORMATION FOR THIS PAGE: Deficiency Type POC Due Date I FACILITY NUMBER: 191200190 VISIT DATE: 09/30/2008 DEFICIENCIES PLAN OF CORRECTIONS(POCs) S&etlon Number 1 FIXTURES, FURNITURE, EQUIPMENT AND Type A 1010612008 Section Cited 101239(e)(4) 2 SUPPLIES. There is currently a toilet not working 3 in this facility. LPA. observed sheets being used to 1 Licensee agrees to have this toilet repaired as this 4 catch water that has overflowed from this toilet as 5 well as puddles of toilet water in the general area o1 6 the bathroOm where children have access. 7 2 shall further ensure the Health and Safety of 3 children receiving care in the facility. 4 5 6 7 1 1 2 2 3 3 4 5 6 7 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 1 2 3 4 5 6 7 2 3 4 5 6 7 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: Knute Martin TELEPHONE: (323) 981-3365 LICENSING EVALUATOR NAME: Paul Zaragosa TELEPHONE: (323) 219-5625 LICENSING EVALUATOR SIGNATURE: :VJ~ l acknowledge receipt of this fonn and undersf4nd my appeal DATE: 01:)/30/2008 fll!hflll!s explalnel! anll "CIIiV!Kl. FACILITY REPRESENTATIVE SIGNATURE: (~~~' This Notice must be posted for 30 days LIC9099 {FAS) - (06104} DATE: 0~/{101201)~ STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY CAUFORNIA DEPARTMENT OF SOCIAL SERVlCES 8 COMMUNITY CARE UCENSING DMSION COMPLAINT INVESTIGATION REPORT LA Child Care East, 1000 Corp. ctr Dr 20QB Monterey, CA 81754 This is an official report of an unannounced visit/investigation of a complaint received in our office on 09/29/2008 and conducted by Evaluator Paul Zaragosa PUBLIC COMPLAINT CONTROL NUMBER: 33-CC-20080929103011 FACILITY NAME: CHILDREN'S COUNTRY HOUSE ADMINISTRATOR: NIELSON, DEBERA ADDRESS: 2821 SANTA ROSA CITY: ALTADENA CAPACITY: 34 MET WITH: STATE: CENSUS: UNANNOUNCED Camille Robinson FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZlP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: 191200190 850 (818) 798-8083 91001 09/3012008 12:30 PM 02:00PM ALLEGATION($): 1 1). Physical Plant-backed up sewer system affecting sink and toilet. 2 3 4 5 6 7 8 9 N 1 2 3 4 5 6 7 6 9 IGATION FINDINGS: Licensing Program Analyst Zaragoza met with teacher, Camille Robinson, to discuss the above referenced allegation. Ms. Robinson stated that she began to notice that last Thursday, she noticed that a toilet was flushing very slowly. The toilet is located to the left, by the entrance, in the only bathroom where two toilets are located. On Friday, the toilet located on the left-side completely stopped wor1 zS,~ DATE: 09/30/2008 This report must be available at Child Care and Group Home facilities for public review for 3 years. LICBOD (FAS) - {06(04) Pag-e: 1 of2 STATE OF CALIFORNIA ·HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCtAL. SERVICES COMMUNITY CARE LICENSING DMSION FACILITY EVALUATION REPORT LA Child Caro East, 1000 Corp. Ctr Dr200B Monterey, CA 91764 FACILITY NAME: CHILDREN'S COUNTRY HOUSE ADMINISTRATOR: NIELSON, DEBERA ADDRESS: 2821 SANTA ROSA ALTADENA CITY: CAPACITY: 34 TYPE OF VISIT: Case Managemeni- Other MET WITH: Camille Robinson FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: STATE:CA DATE: CENSUS:22 UNANNOUNCED TIME BEGAN: TIME COMPLETED: 191200190 850 (818) 798-8083 91001 09/30/2008 12:30 PM 02:00PM NARRATIVE 1 2 3 4 5 ~ 8 9 In conjunction with a field visit made to this facility, the following deficiency is cited in accordance with Title 22, Division 12, of Child Care Centers as indicated .on the page that follows. I An(LICexit9058). interview was conducted and LPA also presented an Appeal Rights form 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME: Knute Martin TELEPHONE: (323) 981-3365 LICENSING EVALUATOR NAME: Paul Zaragosa TELEPHONE: (323) 219-5525 LICENSING EVALUATOR SIGNATURE: 17j~ DATE: 09/30/2008 I acknowledge receipt of this fonm and unders!llnd my licensing appeal rights as expllli!led a!IR recQjved. FACILITY REPRESENTATIVE SIGNATURE: ~) ~ \ "' C l ;s » DATE: Oa/~0/200~ :::> This report must be available at Child Care and Group Home facililiel! fPr public reviell( for 3 r~~r.'· LICSOO {FAS) • {08104) STATE OF CAUFORNIA· HEALTH AND HUMAN SERVICES AGENCY CAUFORNJA.OEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DMSION LA Child Care East 1000 Corp. Ctr Dr 2008 Monterey, CA 91754 10/06/2008 CHILDREN'S COUNTRY HOUSE 191200190 3835 LANDFAIR ROAD PASADENA, CA 91107 Letter of Deficiency Citations Cleared Dear Licensee, The following deficiencies, initially cited during a visit on 09/30/2008, have been cleared: Section Cited: 101238.3(b} Plan of Correction: UC6nsee agrees to find a means to ensure that the bathroom Is kept malnta!ned and cleaned on a dally basis in a manner that is conducive to the Health and Safety of children receiving care In the facU!ty. Date Due: 10/01/2008 Corrections: Clearance Date: Cleared By Visit. LPA's Zaragoza and 10/06/2008 Dumolt observed that the bathroom was clean and maintained. Licensee is cleaning the bathroom with a bleach cleaning solution. LICENSING EVALUATOR NAME: Paul Zaragosa TELEPHONE: (323) 219-5525 LICENSING EVALUATOR SIGNATURE: V~1fil~~~~ DATE: 10/06/2008 This report must be available at Child Care and Group Home facilities for public review for 3 years. Cleared POC Letter (FAS) • (04105) Page: 1 of 1 STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FACILITY EVALUATION REPORT LA Child Care East, 1000 Corp. Ctr Dr 2008 Monterey, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE ADMINISTRATOR: NIELSON, DEB ERA ADDRESS: 2821 SANTA ROSA ALTADENA CITY: CAPACITY: 34 TYPE OF VISIT: POC MET WITH: Camille Robinson FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: STATE: CA DATE: CENSUS: 23 UNANNOUNCED TIME BEGAN: TIME COMPLETED: 191200190 850 (818) 798-8083 91001 10/06/2008 09:40AM 11:15AM NARRATIVE 1 2 3 Licensing Program Analysts Zaragoza and Dumolt met with facility representative, Camille Robinson. 4 5 6 7 LPA's toured the bathroom area to assess corrections previously requested in reports issued 09/30/08. 8 I 9 10 11 12 13 14 15 16 17 18 19 20 21 LPA's toured the rest-room area and observed the toilet requiring repair has been fixed. LPA's also observed that the bathroom has been cleaned and sanitized. After a tour of the facility, all requested corrections have been made. LPA's conducted an exit interview and presented an Appeal Rights form (LIC 9058). 22 23 24 25 SUPERVISOR'S NAME: Knute Martin TELEPHONE: (323) 981-3365 LICENSING EVALUATOR NAME: Paul Zaragosa TELEPHONE: (323) 219-5525 LICENSING EVALUATOR SIGNATURE: ~~~~~;uA DATE: 10/06/2008 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. DATE: 10/06/2008 This report must be available at Child Care and Group Home facilities for public review for 3 years. L1C809{FAS) • (06J04) Page: 1 of 1 CALIFORNIA DEPARTMENT OF SOCiAL SERVICES STATE OF CAUFORNIA ·HEALTH AND HUMAN SERVICES AGENCY COMMUNITY CARE UCENSING DMSION FACILITY EVALUATION REPORT LA Child Care Easl, 1000 Corp. Ctr0r200B Montaray, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE ADMINISTRATOR: NIELSON, DEBERA ADDRESS: 2821 SANTA ROSA ALTADENA CITY: CAPACITY: 34 POC TYPE OF VISIT: MET WITH: Camille Robinson FACILITY NUMBER: FACILITY TYPE: TELEPHONE: STATE:CA ZIP CODE: DATE: CENSUS: 23 UNANNOUNCED TIME BEGAN: TIME COMPLETED: 191200190 850 (818) 798-8083 91001 10/06/2008 09:40AM 11:15 AM NARRATIVE 1 2 3 4 5 61 il 10 I 11 12 13 141 15 Licensing Program Analysts Zaragoza and Dumolt met with facility representative, Camille Robinson. LPA's toured the bathroom area to assess corrections previously requested in reports issued 09/30/08. LPA's toured the rest-room area and observed the toilet requiring repair has been fixed. LPA's also observed that the bathroom has been cleaned and sanitized. After a tour of the facility, all requested corrections have been made. 161 LPA's conducted an exit interview and presented an Appeal Rights form (LIC 17 18 19 20 I 9058). 2'l 22 231 24 25 I SUPERVISOR'S NAME: Knute Martin TELEPHONE: (323) 981-3365 LICENSING EVALUATOR NAME: Paul Zaragosa TELEPHONE: (323) 219-5525 "'!lf~fZT~A9 {FAS} • (0_6/04} Page:1 of1 STATE OF CAUFORNIA- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOClA.L SERVICES COMMUNITY CARE UCENSING DMSION L.A. DAY CARE-EAST 1000 CORPORATE CNTR DR. 200-B MOI\ITEREY PARK, CA 91754 02/05/2009 CHILDREN'S COUNTRY HOUSE 191200190 3835 LANDFAIR ROAD PASADENA, CA 91107 Letter of Deficiency Citations Cleared Dear Ucensee, The following deficiencies, initially cited during a visit on 01/21/2009, have been cleared: Section Cited: 101239.1(cX2) Date Due: 01/30/2009 Pla.n of Correction: Corrections: Licensee submitted s statement Indicating that children's bedding will be stacked in a manner so that it does not come in contact with other childrens 's baddln . Licensee agrees to make provisions to have children's bedding stored In a manner so that bedding does not come into contact with other bedding ln order to further ensure the Health and Safety of ch!l::iren receiving care In this program. Section Cited: 101229.1(aX1) Plan of Correction: Licensee agrees to submit a plan In writing outlining what steps shall be taken In order to ensure that parent/guardians are reminded cf the importance of signing children In/out of th!s program as this further ensure the Health and Safety of children receiving care In this prc~ram. LICENSING EVALUATOR NAME: Paul Zaragosa -ru Clearance Date: 01/27/2009 Date Due: 01/30/2009 Corrections: Clearance Date: 01/27/2009 Licensee submitted a statement in writing Indicating !hat she has notified all parents of the imporiance of signing their children in/out. TELEPHONE: (323) 219-5525 LICENSING EVALUATOR SIGNATURE: !(~ DATE: 02/05/2009 This report must be available at Child Care and Group Home facilities for public review for 3 years. Cloare:f POC Lotter (FAS.- (04/0S) Page: 1 of 1 To Clear Additional POC's Use Button on 809-D STATE OF CAUFORNIA ·HEALTH AND HUMAN S.ERVICES AGENCY CAUFORNIA DEPARTMENT OF SOCIAL SI;RVICES COMMUNITY tARE UCENSING DIVISION CLEARED DEFICIENCIES LA DAY CARE·EAST, 1000 CORPORATE CNTR DR. 200·B MONTEREY PARK, CA 91754 FACILITY NUMBER: 191200190 FACILITY NAME: CHILDREN'S COUNTRY HOUSE VISIT DATE: 01/21/2009 POC Due Date/ Date Cleared I Comments PLAN OF CORRECTIONS(POCs) Section Number 01/30/2009 101216(1) 01/30/2009 Section Cited 101239.1(c)(2) 1 ~ ~censee agrees to make provisions to have staff enroll in 4 ~pproprtate CPR and First Aid training to update certification In 5 rmese fields as this further ensure the Health and Safety of 6 1children receiving care In this program. 7 1 01/27/2009 2 Licensee submitted s statement 3 icensee agrees to make provisions to have children's bedding 1 indicating that children's bedding wlll be 4 btored in a manner so that bedding does not come Into contact 2 stacked in a manner so that it does not 3 come in contact with other childrens 's 5 fwith other bedding in order to further ensure the Health and 6 ~afety of children receiving care In this program. 7 01/30/2009 1 Section Cited 2 3 4 5 6 10j229.1(aX1) 1 2 3 4 Licensee agrees to submit a plan in writing outlining what teps shall be taken in order to ensure that parent/guardians re reminded of the importance of signing children In/out of ~~~-is program as this further ensure the Health and Safety of pnildren receiving care In this program. 4 bedding. 0112712009 1 Licensee submitted a statement in writing 2 indicating that she has notified a!! parents 3 of the Importance of signing their children 4 in/out. 7 01/30/2009 Section Cited 101216(g)(1) 1 2 3fucensee agrees to either locate this completed form or have 41staff undergo health screening as this further ensures the 5 ~ealth and safety of children in care. 6 7 1 2 3 4 To Clear Additional POC's Use Button on 809-D ~TATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CLEARED DEFICIENCIES CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION L.A. DAY CARE-EAST, 1000 CORPORATE CNTR DR. 20G-B MONTEREY PARK, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE POC Due Date I Section Number 01/30/2009 101216(1) F.ACILITY NUMBER: 191200190 VISIT DATE: 01/21/2009 Date Cleared I Comments PLAN OF CORRECTIONS(POCs) 1 ~ Licensee agrees io make provisions to have staff enroll in 1 ppropriate CPR and First Aid training to update certification in 2 3 5 ~~se fields as this further ensure the Health and Safety of 4 6 cnildren receiving care in this program. 4 7 01/30/2009 Section Cited 101239.1(c)(2) 1 01/27/2009 2 Ucensee submitted s statement 3 icensee agrees to make provis~ons to have childr~n·s bedding 1 indicating that children's bedding will be 4 F:~red In a manner so that beddmg does not come mto contact 2 stacked in a manner so that it does not 3 come In contact with other chlldrens 's 5 IW'th other bedding in order to further ensure the Health and 4 bedding. 6 Safety of children receiving care in this program. 7 01/30/2009 Section Cited 101229.1(aX1) 1 2 icensee agrees to submit a plan Jn writing outlining what 3 teps shall be taken in order to ensure that parent/guardians 4 re reminded of the importance of signing children in/out of 5 !this program as this further ensure the Health and Safety of 6 hildren receiving care in this program. 01/27/2009 1 Licensee submitted a statement in writing 2 indicating that she has notified all parents 3 of the importance of signing their children 4 in/out. 7 01/30/2009 Section Cited 101216(g)(1) 1 2 3 Licensee agrees to either locate this completed form or have 41staff undergo health screening as this further ensures the 5 ~ealth and safety of children in care. 6 7 1 2 3 4 STATE Q;: CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CAUFORNtA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FACILITY EVALUATION REPORT (Cont) L.A. DAY CARE.J;AST, 1000 CORPORATE CNTR DR. 200-B MONTEREY PARK, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE DEFICIENCY INFORMATION FOR THIS PAGE: Deficiency Type POC Due Date I Section Number Type B 01/30/2009 Section Cited 101216(1) Type B 01/30/2009 Section Cited 101239.1(c)(2) TypeS 01/30/2009 Section Cited 101229.1(a)(1) DEFICIENCIES 1 PERSONNEL REQUIREMENTS. LPA reviewed 2 staff records and was unable to view current staff 3 certification in CPR and First Aid training. 4 5 6 7 01/30/2009 Section Cited 101216(g)(1) PLAN OF CORRECTIONS(POCs) 1 2 3 4 5 6 7 Licensee agrees to make provisions to have staff enroll in appropriate CPR and First Aid training to update certification in these fields as this further ensure the Health and Safety of children receiving care in this program. 1 NAPPING EQUIPMENT. LPA toured the preschool 1 Licensee agrees to make provisions to have 2 children's bedding stored in a manner so that 2 and obsreved napping cots stacked in a rear 3 section of the preschool. LPA observed children's 3 bedding does not come into contact with other 4 bedding coming into contact with other bedding. 4 bedding in order to further ensure the Health and 5 6 7 5 Safety of children receiving care in this program. 6 7 1 SIGN IN AND SIGN OUT. LPA reviewed sign-in 2 sheets for this program on today's date. Toady's 3 census comprised of (27) children. However, only 1 2 3 4 5 6 7 4 (9) children were actually signed-in. 5 6 7 Type B FACILITY NUMBER: 191200190 VISIT DATE: 01/21/2009 Licensee agrees to submit a plan in writing outlining what steps shall be taken in order to ensure that parenVguardians are reminded of the importance of signing children in/out of this program as this further ensure the Health and Safety of children receiving care in this program. 1 PERSONNEL REQUIREMENTS. LPA was unable 1 Licensee agrees to either locate this completed 2 to locate a Heatlh Screening Reccrd (UC 503) in 2 form or have staff undergo health screening as this 3 further ensures the health and safety of children in 3 the file of Staff: #4. 4 4 care. 5 5 6 6 7 7 Failure to correct the cited deflclency(les), on or before the Plan of Correction (POC) due date, may result In a civil penalty assessment. SUPERVISOR'S NAME: Knute Martin TELEPHONE: (323) 981-3365 LICENSING EVALUATOR NAME: Paul Zaragosa TELEPHONE: (323) 219-5525 LICENSING EVALUATOR SIGNATURE: v~m DATE: 01/21/2009 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2009 LICS09 (FAS)- (06/04) Page: 2 of 3 STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CAUFORNJA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FACILITY EVALUATION REPORT (Cont) L.A. DAY CARE-EAST, 1000 CORPORATE CNTR DR. 200-B MONTEREY PARK, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE FACILITY NUMBER: 191200190 VISIT DATE: 01/21/2009 NARRATIVE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15. 16 17 18 19 20 21 22 23 Staff and children records were reviewed for completeness including but nat limited to Criminal Record Clearances for adults, Director Qualifications and verification of CPR/First Aid and health preventative practices documentation. Review of required forms was made. A review of all facility staff or other individuals who require caregiver background checks was conducted on this date to determine if they have received criminal record and child abuse index clearances or exemptions and/or have provided proof of submission of finger prints to DOJ, FBI and CAlC. MOST RECENT EXEMPTION REGULATIONS DISCUSSED. INTERNET ADDRESS: http:l/www.ccld.ca.gov- To access licensing forms, updates and Title 22. After a complete inspection of the facility, the following deficiencies were observed in accordance with California Code of Regulations Title 22 Division 12 during today's visit as indicated on the page that follows. An exit interview was conducted and an Appeal Rights form (LIC 9058) was also presented. 24 25 26 27 28 29 30 31 32 SUPERVISOR'S NAME: Knute Martin TELEPHONE: (323) 981-3365 LICENSING EVALUATOR NAME: Paul Zaragosa TELEPHONE: (323) 219-5525 LICENSING EVALUATOR SIGNATURE: f~~ DATE: 01/21/2009 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2009 LICB09 (FAS)- (06104} Pago: 3 of 3 STATE OF CALIFORNIA~ HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FACILITY EVALUATION REPORT L.A. DAY CARE-EAST, 1000 CORPORATE CNTR DR. 200-8 MONTEREY PARK, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE ADMINISTRATOR: NIELSON, DEBERA ADDRESS: 2821 SANTA ROSA ALTADENA CITY: CAPACITY: 34 TYPE OF VISIT: Annual/Random Debra Liaison MET WITH: !II ~ ~ I 10 I 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: STATE:CA CENSUS: 27 DATE: UNANNOUNCED TIME BEGAN: TIME COMPLETED: 191200190 850 (818) 798-8083 91001 01/21/2009 10:00AM 12:15 PM NARRATIVE An Annual Site visit was conducted on this date by Licensing Program Analyst's Zaragoza. A complete tour of the facility was conducted. Rooms identified on facility sketch were inspected Furniture and equipment were inspected for age appropriateness and good repair. Telephone service, heating, lighting and ventilation were evaluated. Napping equipment and bedding were inspected. Storage for children's belongings and an isolation area with a sink, toilet, and mats/cots was inspected. Age appropriate sinks and toilets were inspected for availability and good repair. General sanitation was observed. Availability of indoor drinking water was observed. Outdoor play takes place on an adjacent outdoor play space. Outdoor equipment was inspected for safety, cushioning material, good repair and age appropriateness. Required shade, drinking water and fencing were inspected. Play area was inspected for hazards and inaccessibility to bodies of water. Snack/lunch menus were reviewed. Food and snacks were reviewed for availability, quantity and appropriateness to children in care. Food preparation areas were toured for safety, cleanliness. A review of cleaning and food supply storage areas was made. First Aid supplies were inventoried. Please contact your analyst for regulations if considering using Nebulizer or administering Blood-Glucose testing. Teacher child ratios were observed and staff names recorded. Care and supervision was evaluated to determine if the basic needs of children are met. SUPERVISOR'S NAME: Knute Martin TELEPHONE: (323) 981-3365 LICENSING EVALUATOR NAME: Paul Zaragosa TELEPHONE: (323) 219-5525 LICENSING EVALUATOR SIGNATURE: v~ ~l DATE: 01121/2009 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2009 This report must be available at Child Care and Group Home facilities for public review for 3 years. Page: 1 of 3 CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DMSION STATE OF CAUFORN!A- HEALTH AND HUMAN SERVICES AGENCY L.A. DAY CARE-EAST 1000 CORPORATE CNTR DR. 200-B MONTEREY PARK, CA 91754 08/03/2009 CHILDREN'S COUNTRY HOUSE 191200190 3835 LANDFAIR ROAD PASADENA, CA 91107 Letter of Deficiency Citations Cleared Dear Licensee, The following deficiencies, Initially cited during a visit on 03/04/2009, have been cleared: Section Cited: 101161(a) Date Due: 03/06/2009 Plan of Correction: Corrections: Licensee agrees to submit a plan In writing outlining what steps shall be taken to ensure that care is not provided on the upper level of this facll1ty as this further ensures the Health and Safety of children receiving care in this facility. LPA received certification from 03/06/2009 licensee indicating child care will not be Clearance Date: provided on the upper level of this facility and that a pressure gate is in place at the base of the steps during hours of operation of this program. · Section Cited: 101171(a) Date Due: 03/06/2009 Plan of Correction: Corrections: Clearance Date: Licensee agrees to submit a plan in writing outlining what steps shall be taken to ensure that care is not provided on the upper level-ofmrs faclllty as this further ensures the Health and Safety of children receiving care in this facility LPA received certification from 03/06/2009 LICENSING EVALUATOR NAME: Paul Zaragosa licensee indicating child care will not be provided on the upper level of this facility and that a pressure gate is in place at the base of the steps during hours of operation of this program. TELEPHONE: (323) 219-5525 LICENSING EVALUATOR SIGNATURE: f/~. ~y DATE: 08/03/2009 This report must be available at Child Care and Group Home facilities for public review for 3 years. Cleared POC letter (FAS)- (04/05) Page: 1 Of 1 All POC Have Been Cleared STATE OF CALIFORNIA a HEAL.TH AND HUMAN SERVICES AGENCY CAUFO.RNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CLEARED DEFICIENCIES L.A. DAY CARE~EAST, 1000 CORPORATE CNTR OR.200-B MONTEREY PARK, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE FACILITY NUMBER: 191200190 VISIT DATE: 03/04/2009 POC Due Date I Date Cleared I Comments PLAN OF CORRECTIONS(POCs) Section Number 0310612009 101161(a) 03/06/2009 Section Cited 101171(a) Section Cited 1 2 icensee agrees to submit a plan in writing outlining what 3 taps shall be taken to ensure that care is not provided on the 4 ~pper level of this facility as this further ensures the Health and 5 ~-afety of children receiving care in this facflity. 6 7 03/06/2009 1 2 3 4 5 6 7 1 2 3 4 5 6 7 Section Cited 1 2 3 4 1 2 3 4 5 6 7 0310612009 LPA received certification from licensee indicating child care will not be provided on the upper level of this facility and that a pressure gate is in place at the base of the steps during hours of operation of this program. ~P':' r~ceive~ certifica~on from licensee Licensee agrees to submit a plan in writing ouUinlng what teps shall be taken to ensure that care Is not provided on the upper level of this facUlty as this further ensures the Health and s·afety of children receiving care In this facility 1 2 3 4 1 2 3 4 1 2 3 4 mdJcating child care Will not be provided on the upper level of this facility and that a pressure g~te Is In place at th~ base the steps durmg hours of operation of th1s program. a: Control Number 33-CC-20090219095556 STAT:Z OF CAUFORNIA -HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSING OJVISION COMPLAINT INVESTIGATION REPORT (Cont) L.A. DAY CARE-EAST, 1000 CORPORATE CNTR DR. 20G-B MONTEREY PARK, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE DEFICIENCY INFORMATION FOR THIS PAGE: FACILITY NUMBER: 191200190 VISIT DATE: 03/04/2009 Deficiency Typo POC Due Date I Section Number Type A 03/06/2009 Section Cited 101161 (a) Type A 03i06/2009 Section Cited 101171(a) DEFICIENCIES PLAN OF CORRECTIONS(POCs) 1 2 3 4 5 6 7 1 2 3 facility beyond the conditions and limitations specified on the license. Children received care on 4 an unlicensed, upper level of this preschool. Care 5 6 was provided for children who regularly receive 7 care in this preschool program. Licensee agrees to submit a plan in writing outlining what steps shall be taken to ensure that care is not provided on the upper level of this facility as this further ensures the Health and Safety of children receiving care in this facility. 1 2 3 4 5 6 7 FIRE CLEARANCE. Children who are enrolled in this preschool program received care on the upper level of this facility. There is no fire clearance that allows for children to receive care in this section of this preschool program. Further, care was provided for children who regularly receive care in this preschool program. 1 2 3 4 5 Licensee agrees to submit a plan In writing outlining what steps shall be taken to ensure that care is not provided on the upper level of this facility as this further ensures the Health and Safety of children receiving care in this facillty LIMITATIONS ON CAPACITY AND AMBULATORY STATUS. Licensee operated this 6 7 1 2 3 4 5 6 7 1 2 3 1 2 3 4 5 6 7 1 2 3 4 5 6 7 4 5 6 7 Failure to correct the cited deflciency(ies), on or before the Plan of Correction (POC) due date, may result In a civil penalty assessment. SUPERVISOR'S NAME: Knute Martin TELEPHONE: (323) 981-3365 LICENSING EVALUATOR NAME: Paul Zaragosa TELEPHONE: (323) 219-5525 LICENSING EVALUATOR SIGNATURE: r~·~ DATE: 03/04/2009 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: [) L//7/o k This Notice must be posted for 30 days DATE: 03104/2009 STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION ' COMPLAINT INVESTIGATION REPORT L.A. DAY CARE·EAST, 1000 CORPORATE CNTR DR. 200·8 MONTEREY PARK, CA 91764 This is an official report of an unannounced visitlinvestigation of a complaint received in our office on 02119/2009 and conducted by Evaluator Paul Zaragosa PUBLIC COMPLAINT CONTROL NUMBER: 33-CC-20090219095556 FACILITY NAME: CHILDREN'S COUNTRY HOUSE ADMINISTRATOR: NIELSON, DEB ERA ADDRESS: 2821 SANTA ROSA CITY: ALTADENA CAPACITY: 34 STATE: CENSUS: 23 UNANNOUNCED MET WITH: Debera Nielson FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: 191200190 850 (818} 798-8083 91001 03104/2009 10:30 AM 12:30 PM ALLEGATION(S}: 1 LICENSE: Children have received care upstairs in this facility. 2 3 4 5 6 7 8 9 INVESTIGATION FINDINGS: 1 Licensing Program Analyst Zaragoza met with Licensee, Debera Nielson to discuss the above-referenced 2 allegation. LPA also interviewed a separate staff member and several children that were present in this 3 program. 4 5 6 7 8 Three of four children interviewed today confirmed that they have been taken upstairs by a staff member who is employed at this preschool program. Ms. Nielson and this staff member have also confirmed this has occurred. However, staff state that these circumstances have occurred outside the scope and hours of operation of this preschool program. 9 10 The following deficiency is cited in accordance with Tittle 22 Regulations of Child Care Centers as indicated on 11 the page that follows. LPA conducted an exit interview and provided Ms. Nielson with an Appeal Rights form 12 (LIC 9058}. 13 Substantiated Estimated Days of Completion: SUPERVISOR'S NAME: Knute Martin TELEPHONE: (323} 981-3365 LICENSING EVALUATOR NAME: Paul Zaragosa TELEPHONE: (323} 219-5525 LICENSING EVALUATOR SIGNATURE: v~m DATE: 03/04/2009 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: ~nA2~~ /!lA·~ ~ DATE: 0310412009 This report must be available at Child Care and Group Home facilities for public review for 3 years. Control Number 33-CC,20100618093505 STATE OF CAUFORNtA ~HEALTH AND HUMAN SERVICES AGENCY CAUFORMIA DEPARTMENT OF SOClAL. SERVtCES COIIMUNfTYCARE'UCENSING DIVISION COMPLAINT INVESTIGATION REPORT (Cont) CCLO Re;gkmal Offic«<, 1000 CORPORATE..CNTR.DR. 200-B MONTEREY PARK, CA917S4 FACILITY NAME: CHILDREN'S COUNTRY HOUSE FACILITY NUMBER: 191200190 VISIT DATE: 06125/2010 NARRATIVE 1 2 3 4 5 6 7 milieu was clean and rooster appears to be In good health. A rabbtt in a hutch was found to be in good health and hutch is clean. All animal areas were odor free and inaccessible to children. Back area of the facility is fenced and gate locked with a snap ring that is out of reach of children. Back area is overgrown with plant grown and nestied within is a small vegetable garden. Gardening equipment, feed for the animals and discarded classroom furnishings in a garage with a tarp used for a door are atso kept in the back area. Two crawlspaces were found to be screened and secure. 8 9 10 11 12 13 Based on the above, the allegations are deemed unfounded. 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 SUPERVISOR'S NAME: Knute Martin TELEPHONE: (323) 981-3350 LICENSING EVALUATOR NAME: EAnn Dumolt TELEPHONE: (323) 240-6201 LICENSING EVALUATOR SIGNATURE: DATE: 06/25/2010 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATfVE SIGNATURE: DATE: 06/25/201 0 LIC9099 (FAS)- (DB/04) Z' JC l. :•J5ad Page:2of2 (to/90) ~ (SV:J) 6606::H"l "SJee~ t JOJ MB!I\eJ ll!IQAd JOJ S8n!l!lll1,1 ewoH dnoJ€) pue e.~eo Pl!liO ~e GJqeneAe aq :j.flnw ~odaJ S!lll STAlE OF CALIFORNIA· HEAL1lt AND HUMAN SERVICES AGENCY CALIFORNiA DEPARTMENT OF SOCIAl. SERVICES COMMUNITY CARE UCENstNG DMSK>N COMPLAINT INVESTIGATION REPORT CCLD Regional Office, 1000 CORPORATE CNTR DR. 2Q0.9 MONTEREY PARK. CA 81764 This is an official report of an unannounced visit/investigation of a complaint received in our office on 06/18/201 0 and conducted by Evaluator EAnn Dumolt . COMPLAINT CONTROL NUMBER: 33-CC-20100618093505 FACILITY NAME: CHILDREN'S COUNTRY HOUSE ADMINISTRATOR: NIELSON, DEBERA ADDRESS: 2821 SANTA ROSA CITY: ALTADENA 34 CAPACITY: MET WITH: FACILITY NUMBER: FACILITY TYPE: TELEPHONE: STATE: CENSUS: Aireen Mendoza, Ass't Director and Debera Mendoza, Director DATE: TIME VISIT BEGAN: 191200190 850 (626) 798-8083 1}1001 0612512010 09:10AM TIME COMPLETED: 11:14 AM ZIP CODE: ALLEGATION(S): 1 Physical Plant The facility is dirty, illthy. cockroaches in the idtchen. 2 3 4 5 6 7 8 9 INVESTIGATION FINDINGS: 1 j LPA Dumolt and Capt Sanchez of the Los Angeles County Fire Department walked through the facility. LPA 2 . Dumolt inspected facility for cleanliness and vermin. Overan facility wes found to be clean and much improved, 3 e.g., clutter in the classrooms and director's office has been removed. Floors are clean and dust free. They 4 1 are rough but no splintering observed. Licensee has floors cleaned daily and waxed twice a year to minimize 5 J the chance that flooring would splinter. LPA Inspected cupboards above and below sink, overhead cupboards, 6 under appliances on the floor and on the counter tops as well as all closets In the facility. No sign of 7 cockroaches, ants or any other insect or animal was found-not even droppings. Restrooms were checked 8 and were found to be clean and odor free. Doors closed and opened without any problem. The ceiling of the 9 one of the classrooms has sustained water damage from a pipe that had leaked and has been repaired. A 10 patch of the cottage cheese ceiling Is missing and though not aesthetically pleasing is not a threat to the health 11 and safety of children in care. Play yard is dirt with sparse grass. Trees afford shade. Play equipment is in 12 good condition. Yard is fenced. There is a 24 year old pony in a corral that is clean. Pony appears thin but in 13 otherwise in ood health. A rooster was In a covered pen. His Estimated Days of Completion: SUPERVISOR'S NAME: Knute Martin TELEPHONE: (323) 981-3350 LICENSING EVALUATOR NAME: EAnn Dumolt TELEPHONE: (323) 240-6201 UCENSING EVALUATOR SIGNATURE: DATE: 0612512010 1 acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: !Od~_J/JM~ DATE: 0612512010 STATE OF CAUFORNfAa HEALTH AND HUMAN SERVICES AGENCY CAUFORNlA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSING DIVISION FACILITY EVALUATION REPORT (Cont) CCLD Regional Office, 1000 CORPORA-TE CNTR DR. 200-8 MONTEREY PARK, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE DEFICIENCY INFORMATION FOR THIS PAGE: Deficiency Type POC Duo Dote I Section Number TypeS 07126/2010 Section Cited 101238(a) TypeB 0712612010 Sactlon Cited 101215.1 TypeS 0712612010 Section Cited 101212(b)(2) TypeS 0612512010 Section Cited 000000 FACILITY NUMBER: 191200190 VISIT DATE: 06125/2010 PLAN OF CORRECTIONS(POCs) DEFICIENCIES 1 Building & Grounds: Sidewalk in front of building is 2 raised due to tree roots. Sidewalk is broken and 3 poses a hip hazared to children and staff. 4 5 1 Director states1hat llee roots will be cut and 2 removed wHh walkway being replaced. 3 6 7 4 5 6 '7 1 Teacher Qualifications: Copy of Chlid Care Center 2 Teacher permits or official transcripts are needed 3 to show staff #2,3, and 4 are qualified teachers. 4 5 6 7 1 Director states that these will be obtianed and 2 copies placed on file. 3 4 5 6 7 1 Personnel Records: Staff#S need copy ofTB test ·2 results or chest x-ray findings on f!le. 3 4 5 1 Director states that this staff on vacation but will 2 have this compfeted once staff returns to work. 3 4 6 5 6 7 7 1 000000 2 3 4 5 6 7 1 00000 2 3 4 5 6 7 Failure to correct tlhe cited deficiency(ies), on or before tlhe Plan of Correction (POC) due date, may result in a civil penalty assessment. SUPERVISOR'S NAME: Knute Martin TELEPHONE: (323) 981-3350 LICENSING EVALUATOR NAME: EAnn Dumolt TELEPHONE: (323)240-6201 LICENSING EVALUATOR SIGNATURE: DATE: 06/25/201 0 I acknowledge receipt of tlhis form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: JJ&/J/&1_· UC809(FAS) a (OGIG4) DATE: 06/25/2010 Page:40f4 STATE OF CAUFORNIA ~HEALTH AND HUMAN SEIMCES AGENCY CALlFORNIA DEPARTMENT OF 80ClAL SERVICES COMMUNITY CARE LICENSING DMSION FACILITY EVALUATION REPORT (Cont) CCLD Reglona! Offitf,100D CORPORATECNTR DR. 200-B MONTEREY PARK. CA 11754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE FACILITY NUMBER: 191200190 VISIT DATE: 06/25/2010 NARRATIVE 1 2 3 under the swings and climbers. Push toy and trikes are also available for children's use. Animal pens and corral (for rabbit, rooster and pony) are clean and odor free. Animals also appear to be in good health and are allowed out of their pens for daily exercise. Staff were observed to supervise the children around the pony 4' in its corral. LPA DumoH also inspe~ed the records of staff present in the facilily as well as a sampling of children's files. The most resent update of Parents' Rights was printed out and given to Dr. Nielson and is to be used immediately. The edtion being used is over 10 years old. Sign in and sign out sheets were reviewed. ~I 71 8 The following are deficiencies according to theCA Code of Regulations, Title 22, Division 12, Chapter 1 (see 9 next page). 10 11 Copy of report, appeal rights and exit interview given. 12 13 LIC 9213 posted the entry door of facility. 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 SUPERVISOR'S NAME: Knute Martin TELEPHONE: (323) 981-3350 LICENSING EVALUATOR NAME: EAnn Durnell TELEPHONE: (323) 240-6201 LICENSING EVALUATOR SIGNATURE: DATE: 06/25/2010 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: {)~ UC8tl9{FAS) ~{06104) A A /17/ ~~ DATE: 06/25/2010 Page: 3014 CAUFORNlA. DEPARTMENT OF SOCIALSERVlCES STATE OF CAUFORHfA ·HEALTH AND HUMAN SERVICES AGENCY COMMUNITY CARE LICENSING OM8fON CCLD Regional Office 1000 CORPORATE CNTR DR. 200-B MONTEREY PARK, CA 91754 07/09/2010 CHILDREN'S COUNTRY HOUSE 191200190 3835 LANDFAIR ROAD PASADENA, CA 91107 Letter of Deficiency Citations Cleared Dear Ucensee, The following deficiencies, initially cited during a visit on 08/25/2010, have been cleared: Section Cited: 101238(a) Plan of Correction: Date Duo: 07/0912010 Corrgcfions: Clearance Date: Direc\or- that smoke detectors will be insb!lled. Representative Cleanad By Vistt 07/09/2010 Date Due: 07109/2010 Corrections: Cleanad By Vlstt Clearanca Date: 0710912010 of the Department will retum to inspeet. Failure to do so will result in the request fOr a Fire lnspecllon by the State Fire Marshall and administrative .action by the Department. Section Cited: 101238(a) Plan of Correction: Dlrvctt'r stated that these areas will bo cleared and cleaned out Representative of the Depanment will return to Inspect FailUre to do so will ~utt in the request for a Fire Inspection by the state Fire Matshalland administratiVe actlon by tha Deparjmenl Section Cited: Hl1215.1(m) Plan of Correction: Director to have staff#3 register and complete the 15 hour Child Date Oue: ·07/02/201 0 Corrections: Clearance Date: Cleanad By Vistt 07109/2010 Care Provider training certffying Stall 1'3 In pediatric CPR, FilS! Aid and Health and Safety. UCENSING EVALUATOR NAME: EAnn Dumolt TELEPHONE: (323) 240-6201 UCENSING EVALUATOR SIGNATURE: DATE: 07109/2010 This report must be available at Child Care and Group Home facilities for public review for 3 years. Cleared pOC Letter (FAS) • {0410&) Page: 1 of 1 STATE OF CAUFORNIA ·HEALTH AND HUMAN SERVJCES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENS/NG DMSION FACILITY EVALUATION REPORT FACILITY NAME: CHILDREN'S COUNTRY HOUSE ADMINISTRATOR: NIELSON, DEBERA ADDRESS: 2821 SANTA ROSA CITY: ALTADENA CAPACITY; 34 TYPE OF VISIT: Case Management MET WITH: Debera Nielson, Director 1 2 3 4 CCLD Regional Office, 1000 CORPORATI: CHTR DR. 200-B MONTEREY PARK. CA 91764 STATE:CA CENSUS: 18 UNANNOUNCED FACILITY NUMBER: FACIUTY TYPE: TELEPHONE: ZIP-CODE: DATE: TIME BEGAN: TIME COMPLETED: 191200190 850 (626) 796-8083 91001 06125/2010 11:14AM 01:30PM NARRATIVE LPA Dumo~ and Capt. Sanchez met at facility for purpose of inspection and assurance of compliance with the Health and Safety Code for the State of CA. Entire facility and surrounding property was inspected including the living quarters of staff (second floor of facility). Facility is a two story home with a basement. that is just over 100 years old .. 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 The ground floor is primarHy the area used for Child Care and Los Angeles Universal Preschool (operates from September to June). Classrooms found to be orderly and offers a variety of toys, books, manipulatives and educational materials. Doors and exits are free of objects that would prevent exiting the building. Flooring is wood with area rugs. Flooring and area rugs are clean. Heating vents are barricaded or situated so not to be a hazard to children in care. Ventilation and lighting is adequate. Restrooms are clean and odor free. School aged children used a restroom that has a door affOrding privacy. Preschool restroom is open and easily supervised (visually or physically). A changing table is immediately outside the preschool restroom with a sink immediately next to the table. Restrooms are supplied with toilet paper and dispensable soap. Paper towel is supplied to the children by staff. Children are escorted to the restroom Oncluding school age). Kitchen inspected for cleanliness and storage of dry goods and perishable items. Cleaning items are physically separate from food. No vermin or evidence of vennin, e.g., droppings were found in the closets, cupboards, under the sink or under the appliances on th\! floor (refrigerator and d_ishwasher) or those on the countertops (toaster, microwave). Doorto the basement Is locked. Basement was not inspected and was not found to be musty went going down part way on the steps Captain Sanchez and two of his men inspected the back area of the facility and the second floor. They checked the fire extinguisher and smoke detectors of the facility. LPA Dumolt inspected the outdoor activity and found that play equipment appeared to be in good condition. Sand is used as cushioning material SUPERVISOR'S NAME: Knute Martin TELEPHONE: (323) 981-3350 UCENSlNG EVALUATOR NAME: EAnn Dumolt TELEPHONE: (323) 240-6201 LICENSING EVALUATOR SIGNATURE: DATE: 0612512010 I acknowledge receipt of this fonm and understand my licensing appeal rights as explained and received. DATE: 0612512010 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC80ll (FAS) ·{00/04) Pugo:1 of4 STATE OF CAUFORNIA ·HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERvtcES COMMUNfTY CARE UCENSING DMmON FACILITY EVALUATION REPORT (Cont) CCLO Reglon&l Qfflce, 1000 CORPORATE CNTR DR. 200-B MONTEREY PARK, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE FACIUTY NUMBER: 191200190 VISIT DATE: 06/2512010 DEFICIENCY INFORMATION FOR THIS PAGE: Dellclency Type POCDueDate/ Section Number Type A 0710912010 Section Cited 101238(8) PLAN OF CORRECTIONS(POCs) DEFICIENCIES t Building and Grounds: Alt rooms on the second 1 Director states that smoke detuclunl wl~be 2 floor need to have smoke detectors as an 2 installed. Representative of the Department will 3 return to Inspect. Failure to do so will resutt in the 3 employee lives at the facility. It ensures not only 4 the well being and safety of tha employee but the 4 request for a Fire Inspection by the State Fire 5 ~Hdren as well if a lire shoukl sta!too lha1!eCOnd .5 Marshall· and administralivs action by-tha 6 Department. 6 floor. 7 Type A 07109/2010 Section Cited 101238(a) Type A 07/02/2010 Section Cited 101215.1(m) 7 1 Building & Grounds: Back.pnrch on the 1st and 2" 2nd floor as well as the back rooms before these 3 areas need to be cleaned of clutter and dead 4 foliage-these are fire traps and can also attract 5 vermin such as rats. This .poses an immediate ·s threat to staff and children In care. 7 1 ·2 3 4 5 Director stated that these areas will be cleared and cleaned out. Representative of the Department will return to inspect. Failure to do so will result in the request for a Fire Inspection by the State Fire 5 Marshall and administrative action by the 6 Deportment. 7 Director Qualifications: The assistant director, staff 1 2 3 &Safety. 4 #3 opens and closes the facility but does have certification in pediatric CPR, First Aid and Hestth 5 e. Director to have Staff#3 register and complete the 15 hour Child Care Provider training certifying Staff #3 in pediatric CPR, First Aid and Heatth and Safety. 6 7 7 1 2 Type A 3 06/2812010 4 Section Cited 5 .6 101229.1 7 1 2 3 4 Sign In I Out: Of the 18 children In care only 5 are signed in for care. This poses immediate danger if an emergency arises, e.g., fire, and staff cannot give accurate account of who Is in care. Failure to correct the cited deficiency(ies), on or before a civil penalty assessment 1 Director will inform staff to ensure parents sign. in 2 children when arriving at tha facility. 3 4 5 6 7 the Plan of Correction (POC) due date, may result in SUPERVISOR'S NAME: Knute Martin TELEPHONE: (323) 981-3350 UCENSING EVALUATOR NAME: EAnn Dumott TELEPHONE: (323) 240-6201 LICENSING EVALUATOR SIGNATURE: DATE: 06/25/2010 I acknowledge receipt of this fonn and understand my appeal rights as explained anct received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/25/2010 This Notice must be posted for 30 days UC809 !FAS) - (06104) Pqe;2of4 I STATE OF CAUFORHIA -HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT (Cont) FACILITY NAME: CHILDREN'S COUNTRY HOUSE GALIFORNJA DEPAR'lliENT OF SOCIAL SERVICES COMIIIUN11Y CARE UCENSING DMSION CCLO Reglonat Office,.1000 CORPORATECNTR DR. 2(10..8 MONTEREY PARK. CA 11754 FACILITY NUMBER: 191200190 VISIT DATE: 0710912010 There were seventeen signed receipts indicating parents had received a copy of the Type A deficiencies but without a current roster (and the sign in I sign out book does not accurately reflect children who are actually 3 registered & attending the facility now) it was difficult to assess civil penalties. In light of the present economy, 4 LPA Dumolt elected to work with Or. Nielson to bring her Into compliance with not only the sign In and sign out 5 but also with updating children's records (basides staff). A copy of the LIC 9040, Child Care Roster was given as well as the LIC 311A, Records to be Maintained at the Facility-Child Care Centers. 6 7 3) Upstsirs back room had some improvement but is still not cleared according to what the fire department 8 · would like. Room needs to be cleared of the clutter. the papers have to go. Records for the our Department 9 only need to go back 3 years. The 35 years of records can be destroyed. Holiday materials need to be stored 10 in an orderly manner on the shelves. Get rid of the trash. When all is cleared and organized. Consider 11 re-installing-the door or place a barrisade to prevent a chlld from entering the stairwell that leads down into the 12 kitchen-it Is dark and if a child should access the second story, a child could be injured. 13 14 LPA Dumolt will work with Dr. Nielson so that she may be in compliance with both our Department and with 15 L<>S Angeles UniVersal Preschool. 16 Dr. Nielson has agreed to complete the following: 17 1) Mail or fax a copy of the new sign in I sign out sheet 18 2) Go through all the children's iiles and ensure all requiied forms are on iile. Those children enrolled for Los 19 Angeles Universal Preschool wTII hava seclion in their ffie for the LAUP forms. 20 3) Have a child care roster showing all children in care according to the LIC 311A or similar roster that 21 addresses the same information.ofthe LIC 311A. 22 23 LPA Dumo~ wiH return at the end of July to audit the Sign In - Sign out sheets, the children's and staff files 24 and to inspeclthe upstairs storage room. Citations will be issued if the above is not completed and 25 administrative action may be taken. 1 2 26 27 28 29 30 31 32 SUPERVISOR'S NAME: Knute Martin TELEPHONE: (323) 981-3350 LICENSING EVALUATOR NAME: EAnn DumoH TELEPHONE: (323) 240-6201 LICENSING EVALUATOR SIGNATURE: DATE: 07/0912010 I aeknowledge t'EI¢ei¢ ? :wr:B~-~ ~R. December 28,2010 CHILDREN'S COUNTRY HOUSE-191200190 3835 LANDFAIR ROAD PASADENA, CA 91107 Attention: Debera Nielson, PhD. Dear Dr. Nielson, In our last conversation together (8/24/2010) you had expressed a need to correct your current license. Currently on our files, it shows that your license "serves ages 2-8 year olds. Ambulatory only. Capacity includes 30 preschool age children ages 2 through 5 and 4 school aged children ages 6 to 8 years old." A search was made of the original application to add school age and does indicate the ages that you desired to serve was 8 school aged children 6-12 years old. The fire clearance however, limited the number and age range to 4 children ages 6-8 years old. If you wish to serve ages 6-12 you may submit an application to change the age range served. This would allow our Department to submit a request for a fire inspection to determine if children older than 8 but not more than 12 years old may be present. If you choose to do this, I will need facility sketch to indicate where the school age children will be and which is their restroom. I will also need a request for a waiver that allows for staggered play times between the school age children and preschool children. If I do not hear from you, your license will remain the same. However, I will need a waiver request for staggered play times between the preschool and the school aged programs to share the play yard as there none on file. Your response is needed. Please call me at (323) 240- 6201. If I do not hear from you, I will be making a visit to the facility. Without the play yard waiver between the preschool and school age you are out of compliance with Title 22 regulations. Sincerely, E. Ann Dumolt, Licensing Program Analyst Untitled Letter (FAS) • (1~/08) ~.d.x; c .rJe.w J_,·e,u;...u. Mfr-£L:.hk.r c~ ~~:te,; foe /.P~ ~ g(;;"'r'2.d;r /.S..( ;J..orJP ; -Aff f-vr CU.i(J Cw~ C:V.::b!..r.j f_:rc_ ,5'00 1 fvVG.-Jvv,"-"j ~i ~,._.J. 1.5:-c 9 9 9, f'&,j;__,- i .''~-" 5Uft:c\ . STAiE OF CALIFORNIA~ HEALTH AND HUMAN SERVICES AGENCY CAUFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNrrY CARE LICENSING DIVISION CCLD Regional Office 1000 CORPORATE CNTR DR. 200-B MONTEREY PARK, CA 91754 04/15/2011 CHILDREN'S COUNTRY HOUSE 191200190 3835 LANDFAIR ROAD PASADENA, CA 91107 Letter of Deficiency Citations Cleared Dear Licensee, The following deficiencies, initially cited during a visH on 10/19/2007, have been cleared: Section Cited: 191238.2(e) Plan of Correction: Ucensee agrees to replenish theses areas with additional sand and/or other appropriate cushioning materials. Section Cited: 101226(e) Plan of Correction: Uce~see agrees to submit a wrttten plan to the Deparbnent outlining what steps shall be taken to ensure that medications are labelled prop::~rly and dated as well as this further ensures the Health and Safety og Children receiving care in the facility. LICENSING EVALUATOR NAME: Paul Zar Date Due: 11/0212007 Corrections: Ucensee has subnitted a receipt to demonstrate additional sand has been purchased in an effort to replenish cushioning materials. Date Due: 11/0212007 Corrections: Ucensee has submitted a statement cerlifying that she will ensure all medicines for children are current, dated, and named. Clearance Date: 10/20/2007 Clearance Date: 10/20/2007 TELEPHONE: (323) 219-5525 LICENSING EVALU TOR SIGNAT. DATE: 04/15/2011 This report must be available at Child C e nd Group Home facilities for public review for 3 years. Cleared POC Ltrtter (FAS) ~ (04/05) Page: 1 of 1 STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSING DMSION FACILITY EVALUATION REPORT (Cont) CCLD Regional Office, 1000 CORPORATE CNTR DR. 2DD-B MONTEREY PARK, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE FACILITY NUMBER: 191200190 VISIT DATE: 02/04/2014 NARRATIVE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Snack, lunch menus, food and snacks were reviewed for availability, quantity and appropriateness to children in care. Food preparation areas were toured for safety, cleanliness and proper equipment. A review of cleaning and food supply storage areas was made. Outdoor equipment was inspected for safety, cushioning material, good repair and age appropriateness. Required shade, drinking water and fencing were inspected. Play area was inspected for hazards and inaccessibility to bodies of water. Teacher child ratios were observed and staff names recorded. Care and supervision was evaluated to determine if the basic needs of children are met appropriately. Staff was questioned to establish their familiarity of emergency reporting requirements, emergency disaster plans and other site operations. Sign in and out sheets and procedures were reviewed with staff, policy of checking children for illnesses. Personal Rights of children were discussed and observed by LPA. No Transportation policy and procedures were reviewed for safety requirements. Staff and children records were reviewed for completeness including but not limited to Criminal Record Clearances for adults, Director Qualifications and verification of CPR/First Aid and health preventive practices documentation. Inspection of required fonns was made. The following deficiencies were observed in accordance to Title 22 of the California Code of Regulations. See 8090 Page Upon receipt, Licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. -ucensee advised that signing the report does not Imply agreement with the findings but Is acknowledging receipt of the licensing report."*'"" Recent regulatory changes were discussed (including SB 933). Exit interview was conducted including, but not limited to Provider Rights, Appeal Procedures and Agencies Consultative Role. SUPERVISOR'S NAME: Claudia Guangorena TELEPHONE: (323) -98-3381 LICENSING EVALUATOR. NAME: Cynthia Reyes TELEPHONE: (323) 981-3369 LICENSING EVALUATOR SIGNATURE: DATE: 02/04/20.14 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2014 All POC Have Been Cleared STATE OF CALIFORNIA~ HEALTH AND HUMAN SERVICES AGE~~y CALIFORNIA DEPARTMENT OF SOCIAl. SERVICES COMMUNITY CARE LICENSING DIVISION CLEARED DEFICIENCIES CCLO Regional Office, 1000 CORPORATE CNTR DR. 2QD.S MONTEREY PARK, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE POC Due Date I FACILITY NUMBER: 191200190 VISIT DATE: 02/04/2014 Date Cleared I PLAN OF CORRECTIONS(POCs) Section Number 0310412014 101215.1(m) 0310412014 Section Cited 101216(1) 03/0412014 Section Cited 101238(a) Comments 1 2 3 Director states, Pediatric First Aid/CPR will be scheduled and 4 completed. Send a copy of completion certificate to LPA by 5 POC date 6 7 1 2 3 pirector states, Pedialiic First Aid/CPR will be scheduled and 4 pompleted. Send a copy of completion certificate to LPA by 5 POCdate. 6 7 1 2 : Director states will sand and refinish all wood structure by the 5 POCdate. 6 7 02/04/2014 Section Cited 101239 (f) (1) 1 2 ~ ~irector states will have tight fitting lids on all b"ash cans were 5 ood is discarded. 6 7 d 03/03/2014 ~ 03/03/2014 3 Copy of Certificate sent 4 3 Copy of certificate (card) sent 4 d 03/03/2014 3 Picture sent of structure 4 1 03/03/2014 2 Picture sent of trash can with tight fitting 3 lid. 4 STATE OF CAUFORNIA ·HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES FACILITY EVALUATION REPORT (Cont) CCLD Regional Office, 100{1 CORPORATE CNTR DR. 20D·B COMMUNITY CARE LICENSING DIVISION MONTEREY PARK, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE DEFICIENCY INFORMATION FOR THIS PAGE: Deficiency Type POC Due Date I FACILITY NUMBER: 191200190 VISIT DATE: 02/04/2014 PLAN OF CORRECTIONS(POCs) DEFICIENCIES Section Number TypeS 03/04/2014 Section Cited 1C1215.1(m) 1 2 3 4 5 6 7 1 Director states, Pediatric First Aid/CPR will be 2 scheduled and completed. Send a copy of A child care center director shall complete 15 hours 3 completion certificate to LPA by POC date 4 of Health and Safety training. 5 During todays file review there was no current 6 certificate of completion for CPR!First Aid 7 observed. TypeS 03/04/2014 Section Cited 101216(1) 1 2 3 4 5 6 7 Personnel Requirements. At least one person trained in CPR and Pediatric first aid shall be present when children are at the facility or off site activities. During todays file review there was no current certificate of completion for CPR!First Aid observed TypeS 03/04/2014 Section Cited 101238(a) 1 2 3 4 5 6 7 TypeS 02/04/2014 Section Cited 101239 (f) (1) 1 2 3 4 5 6 7 Child Care Center Director Qualifications and Duties. for any staff. 1 Director states, Pediatric First Ald/CPR will be 2 scheduled and completed. Send a copy of 3 completion certificate to LPA by POC date. 4 5 6 7 1 Director states will sand and refinish all wood 2 structure by the POC date. The child care center shall be clean, safe, sanitary 3 and in good repair at all times. LPA observed in the 4 outdoor play yard a Wood play structure and wood 5 101238(a) Buildings and Grounds. titer todder needs sand and refinishing to prevent splinters. This poses a safety hazard to children due to splintering of the wood. 6 7 1 Director states will have tight fitting lids on all trash 2 cans were food is discarded. 3 All trash cans in the facility were food is discarded 4 need a tight fitting lid. LPA obseiVed trash can with 5 6 food discarded in It Is missing a lid. 7 FIXTURES, FURNITURE, EQUIPMENT AND SUPPLIES Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result In a civil penalty assessment. TELEPHONE: (323) -98-3381 SUPERVISOR'S NAME: Claudia Guangorena LICENSING EVALUATOR NAME: Cynthia Reyes TELEPHONE: (323) 981-3369 LICENSING EVALUATOR SIGNATURE: l~c:> DATE: 02/04/2014 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2014 LIC8~9 (FAS) - (06104) Page: 2 of 3 STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DMSION FACILITY EVALUATION REPORT CCLD Regional Office, 1000 CORPORATE CNTR DR. 200·8 MONTEREY PARK, CA fl1754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE ADMINISTRATOR: NIELSON, DEBERA ADDRESS: 2821 SANTA ROSA ALTADENA CITY: CAPACITY: 34 TYPE OF VISIT: Required- 5 Year MET WITH: Debera Nielson FACILITY NUMBER: FACILITY TYPE: TELEPHONE: STATE:CA ZIP CODE: DATE: CENSUS: 17 UNANNOUNCED TIME BEGAN: TIME COMPLETED: 191200190 850 (626) 798-8083 91001 02/0412014 12:25 PM 02:30PM NARRATIVE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 (1) A unannounced 5YR Random site visit was conducted on this date, by Cynthia Reyes, LPA. All areas identified on the Facility Sketch were inspected and checked the following: fingerprint clearances, staff/child ratio, children and staff records, food preparation area, storage and refrigeration, rest rooms, equipment, outside play area and over all conditions of facility. Furniture and equipment were inspected for age appropriateness and good repair. Telephone service, heating, lighting and ventilation were evaluated. Napping equipment and bedding was inspected for good condition, appropriate storage and cleanliness. Bedding identification were inspected. Storage for children's belongings and an-isolation area with a sink, toilet, and mats/cots was inspected. Availability of drinking water was reviewed. Age appropriate sinks and toilets were inspected for availability, good repair, water temperatures, toilet paper, paper towels, area safety and sanitation. First Aid supplies were inventoried. A review of medication policy, including administering, labeling, storage, and records was made. (Please contact your analyst for regulations if considering using Nebulizer or administering Blood-Glucose testing.) A notice of site visit was posted today and licensee was explained that it must remain posted for a period or 3{) days. Failure to keep poster posted will result in a $100.00 civil penalty. SUPERVISOR'S NAME: Claudia Guangorena TELEPHONE: (323) -98-3381 LICENSING EVALUATOR NAME: Cynthia Reyes TELEPHONE: (323) 981-3369 LICENSING EVALUATOR SIGNATURE: DATE: 02/04/2014 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2014 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC809 (FAS) - (06104) Pago: 1 of3 STATEOFCAUFORNlA· HEALTH MD HUMAN SERVJCES AGENCY CAUFORNIA DEPARTMENT OF SOC1AL SERVICES PROOF OF CORRE:CTiON CCI.D Replonal Offu:•, 1000 CORPORATE CNTN DR. 200-B MONTEREY PARK, CA 91764 COII~IDNilY CARE FACILITYNAME: FACIUTYNUMBER: 191200190 CHILDREN'S COUNTRY HOUSE UCEN91NG OMSIOH LICENSING EVALUATOR: Cynthia Reyes This form shall be used In oonjunction with the Licensing Report {LIC 809) and is provided correction of deficiency{ies) cited in a licensing vis~ to your facility on to the facility to verify the 02/04/2014. The use of this form will not prohibit the Licensing Evaluator from conducting follow-up visits to ensure that deficiencies are corrected. {See instructions on page 2). PROOF OF CORRECTION PICTURE RECEIPT PHOTO- *CERTII'ICATION OTHER COf'Y DEFICIENCY(II!S} SECTION NUMilER 1. 2. 3. 4. -- !61-;)Jj, /(m v lold../o(IJ) v' I ~! loL:J/39 (a) 1 o/ ?-.30 !-F 5 ./ DATE CORRECTED. - {}.- :;2'? J ~ /::<.:f' I I I d- j;;;_ '? I I ;;:2 ~~y I 5. 6. 7. 8. - 9. I certify, under penalty of pmjury under the laws of the State of California, that the above is true and correct and that I have corrected all deficiencies above or or before the date(s) indicated. *Certification • this box may be checked if there is no other means to verify that the deficiency has been corrected. Bv signing this form, the licensee is self-certifying that the corrections have been made. If the certification is related to fingerprints. include the name(s) of the individual(s) for which the fingerprint card was submitted and insert the date submitted to the Depa 1ment of Justice in the "Data Corrected" column. PLEASE HETURN THIS FORM WITH YOUR PROOF OF CORRECTION(S) UC901!S (FAS) • {J((l!J) P.11ge: 1 of: HAiE OF CAUFORNL6.~HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office 1000 CORPORATE CNTR DR 200-B MONTEREY PARK, CA 91754 06/23/2014 CHILDREN'S COUNTRY HOUSE 191200190 3835 LANDFAIR ROAD PASADENA, CA 91107 Letter of Deficiency Citations Cleared Dear Licensee, The following deficiencies, initially cited during a visit on 05/09/2014, have been cleared: Section Cited: 101216.3(a) Plan of Correction: Witt. the director on vacation and other teacher off today, lead Teacher realized that parent volunteer needed to be completing the chores rather than her.Corrected on visit. Date Due: 05/09/2014 Corrections: Subsequent visits on 6/06, 6110 and 6/20 of 2014 Director and teachers Clearance Date: 06120/2014 have more than met the teacher child ratio. LICENSING EVALUATOR NAME: EAnn Dumolt TELEPHONE: (323) 240-6201 LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2014 This report must be available at Child Car'! and Group Home facilities for public review for 3 years. Cleared POC lett&T(FAS) w (04/05) Page: 1 of1 All POC Have Been Cleared STATE OF CALIFORNIA- HEALTH AND HUMAN SERV1CES AGE~CY CLEARED DEFICIENCIES CALIFORNIA DEPARTMENT OF SOClAL SERVICES COMMUNITY CARE UCENSING DIVISION CCLD Regional OffiCe, 1000 CORPORATE CNTR OR. 200·8 MONTEREY PARK, CA 91754 FACILITY NUMBER: 191200190 VISIT DATE: 05/09/2014 FACILITY NAME: CHILDREN'S COUNTRY HOUSE POC Due Date I Secrtion Number 05/09/2014 101216.3(a) Date Cleared I Comments PLAN OF CORRECTIONS(POCs) 1 2 1 6 7 1 Section Cited 2 3 4 5 6 1 2 3 4 7 Section Cited 1 2 3 4 5 6 1 2 3 4 7 1 Section Cited 06/20/2014 ·3 ~ith the director on vacation and other teacher off today, Lead 2 Subsequent visits on 6/06, 6/10 and 6/20 4 h'eacher realized that parent volunteer needed to be 3 of 2014 Director and teachers have more 5 completing the chores rather than her.Corrected on visit. 4 than met the teacher child ratio. 2 3 4X 5 6 7 1 2 3 4 Control Number 33-CC-20140502121129 STATE OF CAUFORNIA ·HEALTH AND HUMAN SERVICES AGENCY CAUFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DMSION COMPLAINT INVESTIGATION REPORT (Cont) CCLD Regional Office, 1000 CORPORATE CNTR OR. 2Ql}.B MONTEREY PARK, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE DEFICIENCY INFORMATION FOR THIS PAGE: Deficiency Type POC Due Date I FACILITY NUMBER: 191200190 VISIT DATE: 05/09/2014 DEFICIENCIES PLAN OF CORRECTIONS(POCs) Section Number Type A 05/09/2014 Section Cited 101216.3(a) 1 2 3 4 5 6 7 Teacher Child Ratio: There shall be a ratio of one teacher supervising no more than 12 children in attendance except as specified. A teacher was supervising 18. Even though a parent volunteer was present, the volunteer cannot be counted as part of the teacher child ratio. Lead teacher was busy with chores In facility. 1 2 3 4 5 1 2 3 4 5 6 7 1 2 3 7 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 1 2 3 4 5 6 7 6 4 5 6 7 With the director on vacation and other teacher off today, Lead Teacher realized that parent volunteer needed to be completing the chores rather than her.Corrected on visit. X 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: Joan Hayes TELEPHONE: (323) 981-3380 LICENSING EVALUATOR NAME: EAnn Dumolt TELEPHONE: (323) 240-6201 LICENSING EVALUATOR SIGNATURE: DATE: 0510912014 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: ~ DATE: 05/09/2014 This Notice must be posted for 30 days UC9099 (FAS) • (06J04) Pago: 3 of 3 STATE OF CAUFORNIA~HEALTH CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING OMSION AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT CCLO Rogional Office, 1000 CORPORATE CNTR DR. 20G-B MONTEREY PARK, CA 91754 This is an official report of an unannounced visit/investigation of a complaint received in our office on 05/02/2014 and conducted by Evaluator EAnn Dumolt PUBLIC COMPLAINT CONTROL NUMBER: 33-CC-20140502121129 FACILITY NAME: CHILDREN'S COUNTRY HOUSE ADMINISTRATOR: NIELSON, DEB ERA ADDRESS: 2821 SANTA ROSA ALTADENA CITY: CAPACITY: 34 MET WITH: Airene Mendoza, Lead Teacher FACILITY NUMBER: FACILITY TYPE: TELEPHONE: STATE: ZIP CODE: CENSUS: 18 DATE: UNANNOUNCED TIME VISIT BEGAN: TIME COMPLETED: 191200190 850 (626) 798-8083 91001 05/09/2014 09:45AM 12:00 PM ALLEGATION($): 1 Lack of Care and Supervision: Teacher child ratio is riot met. 2 3 4 5 6 7 8 9 INVESTIGATION FINDING 1 Licensing Program Analyst (LPA) Dumolt met with Ms. Mendoza to address the allegation that teacher child 2 ratio not being met. At the time of the visit, Ms. Mendoza was preparing breakfast for children in care. This left 3 another teacher and a parent volunteer alone with 18 children. Unfortunately, the parent volunteer cannot be 4 counted in the teacher child ratio. With one teacher in the kitchen and the other left alone with 18 children the 5 teacher child ratio is not being met. Later, LPA Dumolt observed the parent supervising a group of children in 6 one room and the other teacher supervising another group of children during breakfast/snack time. The lead 7 teacher was busy taking care of phone calls and tasks around the facility. The allegation ot teacher child ratio is 8 therefore substantiated. 9 10 The following is a deficiency according to theCA Code of Regulations, Title 22, Division 12, Chapter 1 (see 11 following page). 12 13 Copy of report, appeal rights, and exit interview given. Notice of Site Visit posted on door. Substantiated SUPERVISOR'S NAME: Joan Hayes Estimated Days of Completion: TELEPHONE: (323) 981-3380 LICENSING EVALUATOR NAME: EAnn Dumolt TELEPHONE: {323) 240-6201 LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2014 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2014 This report must be available at Child Care and Group Home facilities for public review for 3 years. UC9099 (FAS)- (06104) Page: 1 of 3 CAUFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSING DIVISION STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CCLD Regional Office 1000 CORPORATE CNTR DR. 200-8 MONTEREY PARK, CA 91754 06/23/2014 CHILDREN'S COUNTRY HOUSE 191200190 3835 LANDFAIR ROAD PASADENA, CA 91107 Letter of Deficiency Citations Cleared Dear Licensee, The following deficiencies, initially cited during a visit on 05/09/2014, have been cleared: Section Cited: 101229.1 (a)(1) Date Due: 05/23/2014 Plan of Correction: Corrections: Clearance Data: Sign posted to remind parents to sign in and sign out their children. Staff to monitor and ensure parents comply. This will be rechecked by L?A in 2 weeks Subsequent visits on 6106, 6/10, and 6/20 2014, number of children in care 06123/2014 Section Cited: 101239(1)(1) Plan of Correction: Lead Teacher stated that tight fitting Uds will be added to the trash cam: or new trash cans purchased. LICENSING EVALUATOR NAME: EAnn Durnell has matched number of children signed in. Date Due: 05123/2014 Corrections: Clearance Date: LPA Dumolt noted that on subsequent 06/23/2014 visits for 6/06, 6/1 0, and 6120 2014, that trash cans had tight fitting lids. TELEPHONE: (323) 240-6201 LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2014 This report must be available at Child Care and Group Home facilities for public review for 3 years. Clear&d POC LGtter(FAS) • (04/05) Pago: 1 of 1 All POC Have Been Cleared STATE OF CAUFORNIA- HEALTH AND HUMAN SERVICES !tGENCY CALIFORNIA DEPARTMENT OF SOCiAL SERVICES COMMUNITY CARE UCENSING OMSION CLEARED DEFICIENCIES CCLD Regional Offlce,1000 CORPORATE CNTR DR. 200-B MONTEREY PARK, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE FACILITY NUMBER: 191200190 VISIT DATE: 05/09/2014 POC Due Date I Section Number 05/23/2014 101229.1(a)(1) PLAN OF CORRECTIONS(POCs) 1 2 3 ~ign posted to remind parents to sign in and sign out their 4 ~~ldren. Staff to monitor and ensure parents comply. This 5 f.vill be rechecked by LPA in 2 weeks 6 Date Cleared Comments I 1 06/23/2014 Subsequent visits on 6/06, 6/10, and 6/20 2 20141 number of children in care has 3 matched number of children signed in. 4 7 8 9 10 11 12 13 14 05/23/2014 Section Cited 101239(1}(1) 1 2 3 ead Teacher stated that tight fitting lids will be added to the 4 rash cans or new trash cans purchased. 5 6 7 Section Cited 1 2 3 4 5 6 7 1 2 3 4 06/23/2014 1 LPA Dumolt noted that on subsequent ~ visits for 6/06, 6/10, and 6/20 2014, that trash cans had tight fitting lids. 4 1 2 3 4 CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSING DIVIStoN CCL.D Regional Office, 1000 CORPORATE CNTR DR. 200·8 MONTEREY PARK, CA 91754 STATE OF CAUFORNIA- HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT (Cont) FACILITY NAME: CHILDREN'S COUNTRY HOUSE DEFICIENCY INFORMATION FOR THIS PAGE: FACILITY NUMBER: 191200190 VISIT DATE: 05/09/2014 Deficiency Type POC Due Date I Section Number Type B 05/23/2014 Section Cited 101229.1(a)(1) 1 Sign posted to remind parents to sign in and sign 2 out their children. Staff to monitor and ensure 3 parents comply. This will be rechecked by LPA in shall, at a minimum, include ... the person who signs 4 2weeks the child in/out shall use his/her full legal signature 5 6 and shall record the time of day. LPA Dumolt 7 observed 18 children in care but only 1 2 3 4 5 6 7 Sign in and sign out he licensee shall develop, maintain, and implement a written procedure to sign the child in/out of the child care center that 8 14 were signed in. 9 10 11 12 13 14 TypeB 05/23/2014 Section Cited 101239(!)(1) PLAN OF CORRECTIONS{POCs) DEFICIENCIES 1 2 3 4 5 6 7 Fixtures, Furniture, Equipment and Supplies. AI! storage containers for solid waste, including moveable bins, shall have tight-fitting covers that are kept on, be in good repair, and shall be leak-proof and rodent-proof. Trash can In class room has food waste,and one outside restroom had a soil diaper in trash with no lid. It was noted that 8 trash can in kitchen has a tight fitting lid. 9 10 11 12 13 14 8 9 10 11 12 13 14 1 Lead Teacher stated that tight fitting lids will be 2 added to the trash cans or new trash cans 3 purchased. 4 5 6 7 8 9 10 11 12 13 14 Failure to correct the cited deficiency(ies), on or before the Plan of Correction {POC) due date, may result m a civil penalty assessment. SUPERVISOR'S NAME: Joan Hayes TELEPHONE: {323) 981-3380 LICENSING EVALUATOR NAME: EAnn Dumolt TELEPHONE: (323) 240-6201 LICENSING EVALUATOR SIGNATURE: ~~~~~ DATE: 08/28/2014 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: ~ LICE{I9 (FAS)- {06/04) DATE: 08/28/2014 Page: 2 of2 CALIFORNIA DEPARTMENT OF SOCIAl.. SERVICES COMMUNITY CARE LICENSING DIVISION STATE OF CAUFORNIA ·HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT FACILITY NAME: CHILDREN'S COUNTRY HOUSE ADMINISTRATOR: NIELSON, DEB ERA ADDRESS: 2821 SANTA ROSA ALTADENA CITY: CAPACITY: 34 TYPE OF VISIT: Case Management Aireen Mendoza, Lead Teacher MET WITH: 1 2 3 4 5 6 7 8 CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B MONTEREY PARK, CA 91754 STATE:CA CENSUS: 18 UNANNOUNCED FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 191200190 850 (626) 798-8083 91001 05/09/2014 09:45AM 12:00 PM NARRATIVE Licensing Program Analyst (LPA) Dumolt met with Aireen Mendoza. Tour of facility made. Facility is reasonably clean given the outdoor space is sand and dirt with some grass. Carpeting and flooring is clean. Restrcoms are clean with no odors. Animals and their pens are clean and odor free. They appear in good health. Wooden structure is sanded down in areas used by children who may grab the wood posts when climbing up. Trash can in kitchen has a tight fitting lid for food waste. Lead teacher presented a copy of recent certification in pediatric CPR and First Aid through the American Red Cross (expires 2016). 9 The following is a deficiency of the California Code of Regulations, Title 22, Division 12, Chapter 1 (see next page) 10 11 Copy of report, appeal rights. and exit interview given. 12 13 14 15 16 17 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME: Joan Hayes TELEPHONE: (323) 981-3380 LICENSING EVALUATOR NAME: EAnn Dumolt TELEPHONE: (323) 240-6201 LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2014 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. DATE: 05/09/2014 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC809 (FAS)- (06f04} Page: 1 af2 Control Number 33-CC-20140528140007 STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAl. SERVICES COMMUNITY CARE UCENSING DlvtSION COMPLAINT INVESTIGATION REPORT (Cont) CCLD Regional Office, 1000 CORPORATE CHTR DR. 200·B MONTEREY PARK, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE FACILITY NUMBER: 191200190 VISIT DATE: 06/06/2014 NARRATIVE 1 2 She does the cleaning, cooks lunch, and does help the staff with children. She may assist in activities but she does lead in teaching children. The parent volunteers to defray the cost of child care for her child. 3 4 No deficiencies cited at this time. 5 6 Copy of report, appeal rights, and exit interview given. 7 8 Notice of site visit posted on door. 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 SUPERVISOR'S NAME: Joan Hayes TELEPHONE: (323) 981-3380 LICENSING EVALUATOR NAME: EAnn Dumolt TELEPHONE: (323) 240-6201 LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2014 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: i~h~~ UC9'l99 (FAS)- (OGJG4) DATE: 06/06/2014 Page: 6 of 8 STATE OF CALIFORNIA~ HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT (Cont) CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Offlce,1000 CORPORATE CNlR DR. 200-B MONTEREY PARK. CA 91754 This is an official report of an unannounced visit/investigation of a complaint received in our office on 05/2812014 and conducted by Evaluator EAnn Dumolt COMPLAINT CONTROL NUMBER: 33-CC-20140528140007 FACILITY NAME: CHILDREN'S COUNTRY HOUSE ADMINISTRATOR: NIELSON, DEB ERA ADDRESS: 2821 SANTA ROSA ALTADENA CITY: CAPACITY: 34 STATE: CENSUS: 15 UNANNOUNCED MET WITH: Aireen Mendoza, Teacher; Debera Nielson, Ph.D. FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 191200190 850 (626) 798-8083 91001 06/06/2014 08:40AM 06:00PM ALLEGATION(S): 1 Director yells at children. 2 Staff do not supervise a child who touches inappropriately. 3 4 5 6 7 8 9 INVESTIGATION FINDINGS: 1 Licensing Program Analysts Dumolt and Chico met wtih Ms. Mendoza and Dr. Nielson. LPA Dumolt interviewed 2 teachers 3 and 4 as well as the director. Complainant was interviewed prior to visit. Complainant stated that 3 director would yell at children in a punitive fashion. Complainant also claimed that there is a child who bullies 4 children and touches their private parts when staff are not looking. 5 6 7 8 9 10 11 12 13 Dr. Nielsen admited to yelling at children when outside to direct them away from any activity that could hanm them. She denied ever yelling at a child in way that would make the child feel put down. Dr. Nielsen admitted that the children do at times touch each other inappropriately as a "nonmal part of development." It is not encouraged and children are reminded to respect each other's bodies. But as for a particular child continuously exhibiting this behavior, she and staff 3 and 4 denied this 'occurance. Estimated Days of Completion: TELEPHONE: (323) 981-3380 Inconclusive SUPERVISOR'S NAME: Joan Hayes LICENSING EVALUATOR NAME: EAnn Dumo~ TELEPHONE: (323) 240-6201 LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2014 I acknowledge receipt of this fonm and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2014 This report must be available at Child Care and Group Home facilities for public review for 3 years. ucooae (FAS) ~(llBf04) Page: 5 of 8 STATE OF CALIFORHIA ·HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSING DMSION CCLD Regional Office 1000 CORPORATE CNTR DR. 200-B MONTEREY PARK, CA 91754 06/23/2014 CHILDREN'S COUNTRY HOUSE 191200190 ·3835 LANDFAIR ROAD PASADENA, CA 91107 Letter of Deficiency Citations Cleared Dear Licensee, The following deficiencies, initially ctted during a visit on 06106/2014, have been cleared: Section Cited: 101161(a) Date Due: 06/06/2014 Plan of Correction: Corrections: Clearance Date: Dr, Nielsen stated that she had tried to obtain a Toddler Option. to the best of LPA Oumolrs knowledge. there Is no Toddler Option. Dr. Nielsen finally admltted that he Toddler Optlon·was not granted. She understands that she Js not to enroll children under the age of 2 years old. Cleared at time of visit as child turned 21ast month. 06/06/2014 Section Cited: 10123B(a) Date Due: 06/09/2014 Plan of Correction: Corrections: Clearance Date: Dr. Nielsen believes her maintenance worker may not be doing his job s.s agreed. She will talk to him about his duties and ensure the pens are kept clean and the animals watered. At the time of the visit, Dr. Nielsen made sure the goats and pony were watered. Water In pool for geese was changed. Cleared on 6/20/2014 visit 06/20/2014 LICENSING EVALUATOR NAME: EAnn Dumolt TELEPHONE: (323) 240-6201 LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2014 This report must be available at Child Care and Group Home facilities for public review for 3 years. Cleared POC Letter (FAS) ~ (04105) Page: 1 of 1 All POC Have Been Cleared STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL. SERVICES COMMUNITY CARE LICENSING DIVISIDN CLEARED DEFICIENCIES CClO Regional OffiCe, 1000 CORPORATE CNTR DR. 200.B MONTEREY PARK, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE POC Due Date/ FACILITY NUMBER: 191200190 VISIT DATE: 06/06/2014 Date Cleared I Comments PLAN OF CORRECTIONS(POCs) S&ction Number 0610612014 101161(a) 1 2 3 4 5 6 Dr. Nielsen stated that she ha'd tried to obtain a Toddler Option. to the best of LPA Dumolfs knowledge, there is no oddler Option. Dr. Nielsen flnally admitted that he Toddler oPtion was not granted. She understands that she Is not to nroll children under the age of 2 years old. 1 06/06/2014 2 Cleared at time of visit as child turned 2 3 last month. 4 7 06/09/2014 Section Cltod 101238(a) 1 2 Dr. Nielsen believes her maintenance worker may not be doing ~ 06/20/2014 3 is job as agreed. She will talk to him about his duties and Cleared on 6120/2014 visit 4 ~nsure the pens are kept clean and the animals watered. 3 5 ~t the time of the visit, Dr. Nielsen made sure the goats and 4 6 pony were watered. Water in pool for geese was changed. 7 Section Cited 1 2 3 4 5 6 7 Section Cited 1 2 3 4 5 6 7 1 2 3 4 1 2 3 4 Control Number 33-CC-20140528140007 STATE OF CAUFORNIA-HEALTH AND HUMAN SERVICES AGENCY CAUFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 1000 CORPORATE CNTR DR. 200·8 COMPLAINT INVESTIGATION REPORT (Cont) MONTEREY PARK, CA 91754 FACILITY NAME: CHILDREN'S COUNTRY HOUSE DEFICIENCY INFORMATION FOR THIS PAGE: Deficiency Type POC Due Date I FACILITY NUMBER: 191200190 VISIT DATE: 06/06/2014 DEFICIENCIES PLAN OF CORRECTIONS(POCs) Section Number Type A 06/06/2014 Section Cited 101161(a) Type A 06/09/2014 Section Cited 101238(a) 1 2 3 4 5 6 7 Limitations on Capacity and Ambulatory Status; The licensee shall not exceed the conditions, limitations and capacity specified in the license. At least one Infant was enrolled last Feb 2014 at the age of 21 mos. Infant turned 2 years old May 2014. Another young child was enrolled on his birthday having just turned 2. 1 2 3 4 5 6 7 Dr. Nielsen stated that she had tried to obtain a Toddler Option. to the best of LPA Dumolt's knowledge, there Is no Toddler Option. Dr. Nielsen finally admitted that he Toddler Option was not granted. She understands that she Is not to enroll children under the age of 2 years old. 1 Buildings aryd grounds: Pens for goats and pony 1 Dr. Nielsen believes her maintenance worker may 2 are filled with feces and It Is attracting flies. Water 2 not be doing his job as agreed. She will talk to him 3 for geese is very dirty and malodorous. 3 about his duties and ensure the pens are kept 4 Goat's water is vey low {1 inch) and has feathers 5 and leaves in it. 6 7 4 clean and the animals watered. 5 At the time of the visit, Dr. Nielsen made sure the 6 goats and pony were watered. Water in pool for 7 geese was changed. 1 2 3 4 5 6 7 1 2 3 1 2 3 4 5 6 7 4 5 6 7 1 2 3 4 5 6 7 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: Joan Hayes TELEPHONE: (323) 981-3380 LICENSING EVALUATOR NAME: EAnn Dumolt TELEPHONE: (323) 240-6201 LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2014 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2014 This Notice must be posted for 30 days LICIW99 (FAS)- (OG/04) Page: 3 of 8