<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300600313
Report Date: 05/08/2024
Date Signed: 05/08/2024 11:19:08 AM


Document Has Been Signed on 05/08/2024 11:19 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868



FACILITY NAME:FIRST BAPTIST CHURCH VALLEY DAY PRE SCHOOLFACILITY NUMBER:
300600313
ADMINISTRATOR:HALL, GABRIELFACILITY TYPE:
850
ADDRESS:17415 MAGNOLIA AVENUETELEPHONE:
(714) 847-4844
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:80CENSUS: 30DATE:
05/08/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Director, Gabriel Hall TIME COMPLETED:
11:45 AM
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
Licensing Program Analyst (LPA) Cindy Nguyen conducted an unannounced case management incident inspection in response to a self-report Unusual Incident dated 04/15/2024. LPA met with Director Gabriel Hall. Census was taken in individual classrooms. The overall census observed was 39 preschool children and 10 staff members. A review of adult records indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

On 04/19/2024 a self reported Unusual Incident Report (UIR) was filed with the Licensing Office. The facility reported a child fell from the Monkey Bars onto the wood chips. Parents notified the facility on 04/19/2024 that the child was brought to the hospital for x-rays and determined child's arm had a fracture.

All three staff interviewed stated they didn't observed the incident. Staff #1 (S1) stated the other staff were spread out between the playground, the sandbox and the bathroom with the children. S1 was scanning the playground and when S1 looked at the grass area S1 noticed child #1 (C1) was sitting on the grass quietly crying. S1 called C1 over because S1 couldn't walk away from the gate. S1 asked C1 why child was crying and stated C1's arm hurts. S1 asked C1 for more details and C1 told S1 that C1 was on the monkey bars and C1's hands slipped and C1 fell onto the wood chips. S1 attended to C1 and notified the parents of the incident.

Based on the information gathered from the self reported unusual incident report, interviews with three staff members, a child, statements from the one staff and a physical plant inspection. It was determined that the staff didn't observed the incident. California Code of Regulations, Title 22, Section 101229(a) Responsibility for Providing Care and Supervision is being cited on the attached LIC 809D.

Exit interview was conducted with Director Gabriel Hall. Notice of Site Visit was posted during the visit. Director was informed that the notice of site visit must be posted for 30 consecutive days. Continued on Page 809C.

SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 743-5149
LICENSING EVALUATOR NAME: Cindy NguyenTELEPHONE: (714) 296-3608
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 05/08/2024 11:19 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868


FACILITY NAME: FIRST BAPTIST CHURCH VALLEY DAY PRE SCHOOL
FACILITY NUMBER: 300600313

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/22/2024
Section Cited
CCR
101229(a)

1
2
3
4
5
6
7
101229 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the children's needs. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Director stated the child care staff will have a training on supervision including visual obsrevation. A list of signatures of the staff attened the meeting email to LPA Nguyen (Cindy.Nguyen@dss.ca.gov) by 5/22/2024.
8
9
10
11
12
13
14
Based on interviews from the three staff, it was disclosed that staff did not observed how the injury occur. This is a potential risk to the health and safety of children in care.
8
9
10
11
12
13
14

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: Patricia MaganaTELEPHONE: (714) 743-5149
LICENSING EVALUATOR NAME: Cindy NguyenTELEPHONE: (714) 296-3608
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: FIRST BAPTIST CHURCH VALLEY DAY PRE SCHOOL
FACILITY NUMBER: 300600313
VISIT DATE: 05/08/2024
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
Page LIC 809C

Failure to post will result in civil penalties of $100. Director was provided a copy of their appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. First level appeals should be sent to the regional manager to the address listed above.
SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 743-5149
LICENSING EVALUATOR NAME: Cindy NguyenTELEPHONE: (714) 296-3608
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3