Routine inspection·May 6, 2026

Licensing Program Analyst (LPA) Nolan Tcheng conducted an unannounced random annual inspection. Upon arrival at 8:40am, LPA met with Facility Representative Xochitl Bajo. At 9am, LPA was led on a tour of the facility. This is a Pasadena Unified School District Preschool program which consists of 1 classroom. Facility is located on the campus of Sierra Madre Elementary School. Per licensee, there are currently 19 enrolled in the program (10 in the AM session, and 9 in PM session). Hours of operation for this facility are 7:45-10:45 (AM Session)/11:15am-2:15pm (PM session). Licensing staff observed all required forms/publications to be posted by entrance. Snack menus were reviewed to ensure that they are being posted one week in advance where it is visible by the child's authorized representative. Menus for the past 30 days are available upon request. At 9am, LPA entered and inspected Sierra Madre (Room 127): 7 children with 6 staff members. Disinfectants, cleaning solutions, medication and other items that are dangerous to children, were inaccessible to children. During review of Medication, LPA observed that 2 of 6 medications stored had an expiration date that had passed which is a potential risk to the children in care. Facility Representative states they will immediately have the authorized representatives replace the medication. Furniture and equipment are in good condition, free of sharp, loose, or pointed parts. All floors are clean and safe. Due to split session schedule, there is no nap equipment. All storage containers for solid waste, including moveable bins shall have tight-fitting covers that are kept on, and in good repair. Trash cans used to discard food have tight fitting lids. The facility was observed to be free of flies, other insects and rodents. Sufficient individual storage space for children was observed and each child has a cubby. Drinking water was readily available indoors. At this time, the Calm Area is used as an isolation area. A mat is available for an ill child to rest on. Facility representative states there are no weapons, firearms, or bodies of water on the premises. REPORT CONTINUES PAGE 1 of 3 At 9:10am, a fire extinguisher was observed. The valve on the required 2A 10BC fire extinguisher indicates fully charged and was serviced on 12/12/2025 , as indicated on service tag. Per State Fire Marshall standards, fire extinguishers shall be serviced annually. First Aid supplies are available and complete. Facility has a functioning carbon monoxide detector that meets statutory requirements. There is a restroom in the classroom for children in care. All toilets, hand washing, and bathing facilities are safe, sanitary and are operating properly. Food and meals are provided by the elementary school and not prepped in the classroom. This facility provides breakfast for AM session and lunch for PM session. At 9:25am, LPA reviewed the outdoor play area. Outdoor playground equipment is in safe condition, free of sharp, loose or pointed parts. The surface of the outdoor activity space is maintained in a safe condition and is free of hazards. All areas around or under high climbing equipment, slides, and similar equipment are cushioned with material that absorbs a fall. There is one outside play space with play structure, play house, bikes, sandbox, and toys/equipment. Drinking water is readily available outdoors. Teacher-child ratios were observed to be in accordance with Title 22 and Title 5 regulations. Staff names were recorded. All children were observed to be under visual supervision of a teacher during tour. The Licensee is within the conditions, limitations, and capacity specified on the license. All areas were identified on the Facility Sketch were inspected. At 9:40am,, facility records were reviewed. Sign in and out was reviewed on an electronic tablet. Facility utilizes an application, Hubbe, that allows families to sign their child in an out with time of day. Disaster drills have been conducted at least every six months. Staff files were not reviewed during today's inspection as Staff files are stored at the Pasadena Unified School District office. They will be reviewed at a later date. A random sample of Children’s Records were reviewed on Hubbe to ensure that they are complete. To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process Facility Representative was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California. REPORT CONTINUES PAGE 2 of 3 Facility Representative was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated. Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test. For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1- CCP). LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP This facility provides Incidental Medical Services – IMS. LPA reviewed storage of “medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication. Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-carecenters/ 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 for deficiencies that are being cited and need to be cleared to protect the children’s health & safety. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with Facility Representative Xochitl Bajo, at 10:20am. Copy of Report provided. END OF REPORT