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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300605744
Report Date: 05/22/2025
Date Signed: 05/22/2025 11:49:04 AM

Document Has Been Signed on 05/22/2025 11:49 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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:DOLPHIN CLUB DAY CARE CENTER, THEFACILITY NUMBER:
300605744
ADMINISTRATOR/
DIRECTOR:		GONZALES, KARIFACILITY TYPE:
840
ADDRESS:155 EASTSHORETELEPHONE:
(949) 651-0152
CITY:IRVINESTATE: CAZIP CODE:
92604
CAPACITY: 135TOTAL ENROLLED CHILDREN: 135CENSUS: 4DATE:
05/22/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Gonzales, Kari (Director)TIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vivian Trinh conducted an on-site inspection for a self reported incident on 4/4/2025. The Director, Gonzales, Kari, was informed of the purpose of the visit, and a tour of LPA around the center was completed. The census included 4 school-age children and 3 staff members

A review of the Facility Personnel Report Summary conducted on today’s date 5/22/2025 indicates all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.

On 4/8/2025, an Unusual Incident Report was filed with the Department to self-report an incident that occurred on 4/4/2025. It was reported that Child #1 (C1) exhibited inappropriate behaviors toward other children in the classroom, and the facility had taken actions to address concerns about the child’s appropriate behavior.

During the investigation, LPA interviewed five (5) staff members and two (2) children and obtained a copy of the children's roster, LIC 500, Parents Handbook, facility roster, and the email communication with parents.

LPA interviewed five (5) staff members. All staff members stated that they did not witness the incident in which C1 exhibited inappropriate behaviors toward other children in the class. However, when facility staff was informed of the incident by Child #2 (C2)’s parent, the Director conducted an internal investigation, interviewed staff and children, informed the involved parents, and suspended C1 until further notice.

Continued page 2.

Nguyen K TranTELEPHONE: (714) 658-6048
Vivian TrinhTELEPHONE: (949) 466-1624
DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: DOLPHIN CLUB DAY CARE CENTER, THE
FACILITY NUMBER: 300605744
VISIT DATE: 05/22/2025
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LPA interviewed Child 2 (C2) and Child 3 (C3) and stated that C1 exhibited inappropriate behaviors while in the classroom, and the teacher was not aware to intervene. LPA interviewed 5 parents. Three (3) parents out of the five (5) interviewed parents confirmed they received written notification from the facility regarding the incident and were aware of the facility’s actions taken to address concerns surrounding the incident.

During the record review, the facility has conducted staff meetings to address supervision and resolve student conflicts.

Based on LPA interviews and record review, the deficiency is observed according to the California Code of Regulations, Title 22: 101229(a)(1) Responsibility for Providing Care and Supervision. Please refer to the attached 9099D for documentation of deficiencies.



An exit interview was conducted with Director Kari Gonzales. The Notice of Site Visit was posted for at least 30 consecutive days. Appeal Rights were explained.

The End of Report.

SUPERVISOR'S NAME: Nguyen K TranTELEPHONE: (714) 658-6048
LICENSING EVALUATOR NAME: Vivian TrinhTELEPHONE: (949) 466-1624
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 05/22/2025 11:49 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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868


FACILITY NAME: DOLPHIN CLUB DAY CARE CENTER, THE
FACILITY NUMBER: 300605744

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/22/2025
Section Cited
CCR
101229(a)(1)

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101229(a)(1) Responsibility for Providing Care & Supervision: No child(ren) shall be left without the supervision of a teacher at any time... Supervision shall include visual observation. This requirement is not met evidenced by:
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The Director states she has provided training for their staff regarding care and supervision strategies for the children in care, and continued to train staffs. The director submitted proof of training to LPA during the visit.

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Based on interviews, five (5) interviewed staff members who were providing supervision for the children in the facility in the classroom on 04/04/2025 confirmed that they were not aware of the incident in which C1 exhibited inappropriate behaviors with other children in the class. This poses a potential risk to the health, safety, and personal rights of the children in care..
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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.
Nguyen K TranTELEPHONE: (714) 658-6048
Vivian TrinhTELEPHONE: (949) 466-1624

DATE: 05/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2025

LIC809 (FAS) - (06/04)
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