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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300605677
Report Date: 04/27/2022
Date Signed: 04/27/2022 10:47:01 AM


Document Has Been Signed on 04/27/2022 10:47 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:TUSTIN PRESCHOOLFACILITY NUMBER:
300605677
ADMINISTRATOR:CORDOVA, JANICEFACILITY TYPE:
850
ADDRESS:14211 NEWPORT AVENUETELEPHONE:
(714) 838-3480
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY:45CENSUS: 27DATE:
04/27/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Janice CordovaTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Valencia conducted an on site inspection for the purpose of a Case Management Incident inspection, in response to an Unusual Incident Report submitted to the Licensing office on 4/21/22. LPA conducted a tour of the facility at approximately 9am. The overall census observed was 27 preschool children with 3 preschool staff. A review of the Facility Personnel Report Summary on this date indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

A telephone unusual incident report was submitted to the Licensing office on 4/21/22 detailing that a child #1 (see Confidential Names List LIC811) had been kicking and screaming other children and a staff, and a staff #2 picked up child to take them to the outdoor play area. C1 then dropped weight and fell to the wood chip cushioning on the outdoor play area. LPA conducted a physical plant inspection of the facility, observed the classrooms/physical plants, interviewed 3 staff and child #1 about the incident and personal rights at the facility. LPA attempted to interview a possible adult witness, adult #1. It was determined from the information available to LPA during the inspection and investigation into the incident involving child #1 on 4/20/22, that the the facility staff did not violate child #1's personal rights, related to this reported incident on 4/20/22. The facility was not issued any violations as a result of this incident and were determined to have complied with Title 22 Personal Rights. A printout of Title 22 Regulation Personal Rights 101223 was reviewed and provided to the facility representative during the inspection.

During the physical plant walk through and census of children taken, LPA observed that the facility was, and on occasion does, operate out of compliance of 1 teacher to 12 children ratio. It was observed that 3 teachers were supervising 27 children, and Director needed to leave ratio to open the front door of the facility. If any staff were to use the restroom or leave the group at all for any reason, food preparation, opening front door, illness, errand, etc, then the facility would be operating out of ratio, and is not able to operate within compliance of Title Regulations Ratio under these circumstances. (continued on LIC809C)
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Dean ValenciaTELEPHONE: (714) 215-6737
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: TUSTIN PRESCHOOL
FACILITY NUMBER: 300605677
VISIT DATE: 04/27/2022
NARRATIVE
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Based on LPAs observations the following violation is being cited in accordance with California Code of Regulations, Title 22 Section 101216.3(a), is being cited on the attached LIC 809D.

Due to the facility being cited a Type A violation, the licensee must post and provide copies of the report to parents/guardians of the children in care at the facility by the next business day, and shall provide to the parents/guardians of children newly enrolled at the facility during the next 12 months. In addition, the licensee shall immediately post upon receipt the Proof of Correction for 30 consecutive days and provide a copy to current and enrolling parents. The licensee is to keep Acknowledgement Receipt (LIC 9224) signed by parents in each child’s file. Failure to post Type A reports for 30 days will result in a Civil Penalty of $100.00

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. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Dean ValenciaTELEPHONE: (714) 215-6737
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/27/2022 10:47 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: TUSTIN PRESCHOOL
FACILITY NUMBER: 300605677

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/27/2022
Section Cited

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RATIO: There shall be a ratio of one teacher visually observing and supervising no more than 12 children in attendance,
This was not met as evidenced by:

Based on LPA observations, it was determined that the facility allows for 1 teacher to supervise more than 12 preschool
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children, at one time. This presents an immediate threat to the children's health and safety.
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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: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Dean ValenciaTELEPHONE: (714) 215-6737
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2022
LIC809 (FAS) - (06/04)
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