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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 300605470
Report Date: 07/21/2022
Date Signed: 08/24/2022 07:39:54 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/15/2022 and conducted by Evaluator Stella Gutierrez
PUBLIC
COMPLAINT CONTROL NUMBER: 06-CC-20220715162930
FACILITY NAME:ST. ANDREW'S CHILDREN'S CENTERFACILITY NUMBER:
300605470
ADMINISTRATOR:JONES, CAROLYNFACILITY TYPE:
830
ADDRESS:4400 BARRANCA PARKWAYTELEPHONE:
(949) 651-0198
CITY:IRVINESTATE: CAZIP CODE:
92604
CAPACITY:64CENSUS: 31DATE:
07/21/2022
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Pamela Myles, progrma specialist TIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Personal Rights- child sustained injury while in care
INVESTIGATION FINDINGS:
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This report has been amended.
On 07/21/2022 Licensing Program Analyst, Stella Gutierrez made an unannounced visit to St. Andrew Children’s Center for the purpose of a complaint received. Upon arrival, LPA was met by Pamela Myles, program specialist who was explained the reason for today’s visit. LPA was provided a tour and observed 14 Infant staff and 31 Infant children present.
A review of the Facility Personnel Report Summary conducted on 07/21/2022 indicates all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.
A complaint was received of the allegation mentioned on this report, personal rights - a child sustained an injury while in care at the facility. On 06/20/2022 an infant child was observed by a staff member falling out of a crib at the facility. During today’s investigation LPA, Gutierrez reviewed records for the infant child (C#1) that sustained injuries, interviewed Director and interviewed the 03 staff that were present at the facility when the incident occurred on 06/20/2022. Page 1 of 3
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Stella GutierrezTELEPHONE: (714) 293-5262
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 06-CC-20220715162930
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: ST. ANDREW'S CHILDREN'S CENTER
FACILITY NUMBER: 300605470
VISIT DATE: 07/21/2022
NARRATIVE
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This report has been amended.
It was revealed that on 06/20/2022 C#1 was napping in a crib while at the facility. While C#1 was placed in crib during the transition for nap time Staff #1 observed C#1 throw a blanket out of the crib. C#1 was able to elevate himself/herself to try and reach for the blanket that had fallen from the crib. S#1 stated that they observed C#1 fall out of the crib while reaching for the blanket resulting in C#1 hitting their head on the carpet floor. Staff#1 also stated that they tried to made their way over to the crib to avoid child having to reach for the blanket and falling, but it was too late. Staff #1 stated that they were in the infant sleeping area when the incident occurred.
Reporting party was interviewed on 07/15/2022. RP took the infant child to seek immediate medical attention on 06/20/2022, RP stated the C#1 suffered minor injuries (some swelling to the forehead and right shoulder pain) Infant records review did not specify any special accommodates while in C#1 was in care at the facility.
During the investigation and today’s interviews, it was revealed that an infant child in care sustained an injury while in care on 06/20/2022. C#1 was able to fall out of a crib which violates the personal rights of C#1 not provided a mat or cot while in napping at the facility. It was further revealed that when C#1 sleeping in crib was not free of lose articles during nap time at the facility infant center. C#1 was provided a blanket in a crib during nap time by Staff #1 at the facility. During Staff #1 interview today, it was stated that C#1 is provided the blanket and once the child falls asleep at the facility, the blanket is taken away. Safe Sleep consultation provided to Director and Staff #1 during today's inspection. A Technical Violation in accordance to Title 22 regulation 101439.1 (f) was given today. During records review it was further determined that the facility did not report the unusual incident that occurred at the facility on 06/20/2022 to their local licensing agency. During the interview with the Director is was stated that a staff member attempted to report the incident to licensing. Staff #1 stated that an incident report was provided to the parent or authorized representative of C#1, but there was no report provided nor received of the incident to Community Care License, Orange County Regional Child Care Program Office. During the interviews, all staff stated that was no report provided to CCLD regarding the incident and there was no evidence of an LIC 624 (Unusual Incident report) faxed, emailed or received.

Based on interviews and records reviewed the allegation referenced on this report is substantiated. A substantiated finding means that the complaint is substantiated, and the allegation is valid because the preponderance of the evidence standard has been met.

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SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Stella GutierrezTELEPHONE: (714) 293-5262
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 06-CC-20220715162930
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: ST. ANDREW'S CHILDREN'S CENTER
FACILITY NUMBER: 300605470
VISIT DATE: 07/21/2022
NARRATIVE
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The following violations were revealed and is being cited in accordance with California Code of Regulations, Title 22, Division 12, Chapter 1, sub chapter 02, Infant care center sleeping equipment 101439.1 ( c) , and California Code of Regulations, Title 22, Division 12, Chapter 1, Article 06 101212 (d) (1) ( C) Reporting Requirements. Type A and Type B deficiencies will be cited today and a civil penalty will be assessed. Please refer to attached 9099 (D) .

LPA, Stella Gutierrez informed Carolyn Jones, director that this report dated 07/21/2022 documents of 01 Type A citations which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care. Also, LPA, Stella Gutierrez informed the director to provide a copy of this licensing report dated 07/21/2022 that documents any Type A citations to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Exit interview conducted and report was reviewed with the director, Carolyn Jones. Appeal Rights and deficiencies were discussed. The facility representative was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days.

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SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Stella GutierrezTELEPHONE: (714) 293-5262
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 06-CC-20220715162930
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: ST. ANDREW'S CHILDREN'S CENTER
FACILITY NUMBER: 300605470
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/28/2022
Section Cited
CCR
101439.1(C)
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101439.1Infant Care Center Sleeping Equipment- (c) Floor mats or cots that meet the requirements of Section 101239.1(b) shall be provided for all infants who have the ability to climb out of a crib.
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The director was provided a consultation and agrees with LPA that providing the infant staff at the facility with a training on when to identify the needs of a child needing to be transitions to a mat or a cot when having the ability to climb or fall from a crib at the facility. Director will conduct a meeting/training for
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This requiment was not met as evidence by statements during today's interviews that the incident did occur at the facility. This poses as an immediate risk to the Infant children in care. The facility did not provide C#1 with a mat or cot while in care when having the ability to climb or fall from a crib resulting in the child sustaining an injury while in care.
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the infant staff at the center, providing an agenda and the names or staff who attended (role sheet with staff signature) by the specified date of 07/28/2022 via email to stella.gutierrez@dss.ca.gov
In addition to a Type A citation an immediate civil penalty will be assessed today.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Stella GutierrezTELEPHONE: (714) 293-5262
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 06-CC-20220715162930
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: ST. ANDREW'S CHILDREN'S CENTER
FACILITY NUMBER: 300605470
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/21/2022
Section Cited
CCR
101212(d)(1)(C)
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101212 Reporting Requirements (d) Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. (1)

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It was discussed with the director of the obligation of reporting requirements and a copy of this regulation was provided during today's consultation. Director stated that she understands moving forward after today's inspection. Type B citation cleared during today's inspection.
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 (C)Any unusual incident or child absence that threatens the physical or emotional health or safety of any child.
This requirement was not meant as evidence by records review and statements. The facility did not report the incident that occurred to CCLD verbally or on a written LIC 624).
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Stella GutierrezTELEPHONE: (714) 293-5262
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5