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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 300606476
Report Date: 08/26/2022
Date Signed: 08/26/2022 03:12:35 PM

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
06/20/2022 and conducted by Evaluator Carmen Odom
PUBLIC
COMPLAINT CONTROL NUMBER: 06-CC-20220620101702
FACILITY NAME:GRACE HARBOR CHURCH AND SCHOOLFACILITY NUMBER:
300606476
ADMINISTRATOR:DOWNING, CHRISTINEFACILITY TYPE:
830
ADDRESS:12881 NEWPORT AVENUETELEPHONE:
(714) 544-4431
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY:16CENSUS: 7DATE:
08/26/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Rebakah Bay - DirectorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Daycare child sustained pink eye.
Classroom operating out of ratio.
Staff not meeting daycare child’s diapering needs resulting in a diaper rash.
Staff does not provide clean and sanitary environment.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Odom conducted an unannounced complaint investigation. This is a continuation of the investigation initiated on 6/28/2022. Upon arrival LPA met with Director Rebekah Bay to deliver complaint findings. At 9:00am, LPA observed a total of 7 children and 3 staff; 5 Infants in the infant room (0-12 months) with 2 staff, 2 toddlers in toddler room (12-24 months) with 1 staff. Facility was operating within ratio.

A review of staff records on this date indicated that all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.

The Department received a complaint on 6/20/2022 alleging daycare child sustained pink eye, staff do not provide clean and sanitary environment, classroom operating out of ratio and staff not meeting daycare child’s diapering needs resulting in a diaper rash.
Continue to page 2.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Carmen Odom
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022
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-20220620101702
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: GRACE HARBOR CHURCH AND SCHOOL
FACILITY NUMBER: 300606476
VISIT DATE: 08/26/2022
NARRATIVE
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The complainant party (CP) reported 2 infants had pink eye and CP observed staff #2 (S2) does not clean and sanitize the infant toys, and classroom. CP disclosed the first week of June a staff was left with 6 infants alone and S2 does not change children’s diapers frequently resulting in diaper rashes.

During the investigation LPA Odom interviewed complaining party, Director, and 6 staff members. LPA reviewed the Children’s Roster, personnel report, personnel records, time sheets, sign in and out sheets, and ProCare daily reports. Children were not interviewed due to the age group (0 month to 24 months) all the children are nonverbal and could not be qualified to interview.

During an interview on 7/11/2022, the Director (S6) stated, recently there were outbreaks of Pink Eye and Hand, Foot & Mouth in the infant center. 1 child had Pink Eye and there were a few children that had Hand, Foot, Mouth disease. The children were sent home with a notice that they were not allowed to return to the childcare center until after 24 hours and with a doctor note. S6 was not aware if the outbreak was reported to Orange County licensing office or Department of Public Health. The staff are supposed to clean and disinfect daily during the day and a janitor cleans the classroom in the evening. Staff are supposed to use the booties in the infant classroom, but they were not being used due to slipping hazard. Staff have been provided slippers to wear while in the infant classroom only. S6 stated the infant classrooms have a daily schedule in which includes diaper changing and staff are supposed to document on the ProCare App every time the infant’s diaper is changed. If an infant has a diaper rash staff will notify the parents and parents will provide diaper rash cream. According to ProCare App staff have noted when diaper cream has been placed on child.
S6 disclosed they were not aware staff #4 (S4) was left alone with 6 infants while staff #7 (S7) left to another classroom to assist with diaper changing

Staff #1 (S1) stated on 5/27/22 at 3:00pm while working as a floater they observed S4 was alone with 6 infants in the toddler room for about 15 minutes, because S6 told S7 to go to the 2-year-old classroom and assist with diaper changing. S4 confirmed the incident that occurred on 5/27/22. S4 disclosed S6 was not familiar with the routine and S6 sent S7 to the 2-year-old classroom to assist with diaper changing. S4 disclosed they were alone for 10 minutes.

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SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Carmen Odom
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 06-CC-20220620101702
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: GRACE HARBOR CHURCH AND SCHOOL
FACILITY NUMBER: 300606476
VISIT DATE: 08/26/2022
NARRATIVE
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Page 3
LPA Odom interviewed five staff members on 7/11/2022 and 8/11/2022. Three out of the five staff confirmed that C1 in the infant classroom had Pink Eye and there were multiple cases of infants with Hand, Foot, Mouth disease. S2 stated C1 arrived at the childcare with gunky eyes and they were sent home for 24 hours. All the staff disclosed they disinfect the classroom and toys daily.

Staff #3 (S3) stated they observed S2 would not change the infant’s diapers according to the daily schedule. The days they had to work in the infant classroom S2 wouldn’t change the infant’s diaper and wait for S3 to change the infant’s soiled diaper. S3 would observe the poop dry and sticky as if it was sitting there for a while and infant’s bottom would be red. Staff #5 (S5) stated they have observed infant’s getting diaper rash while in care and S2 will verbally say they have changed child’s diaper but they don’t document it on the ProCare App. S5 has reminded S2 to make sure they are documenting every diaper change on the ProCare App. S2 stated they will check the infants diaper every hour and half unless they have a bowl movement. S2 stated there have been a few infants with diaper rash, they will put ointment that parents provide and document it. According to the ProCare App on 6/15/22 Child #2 (C2) did not have a diaper change after 4 hours.

Based on LPA facility inspection, observation, interviews conducted with complainant party, director, staff members, and records reviewed it has been determined that C1 sustained pink eye, toddler room was operating out of ratio, S2 does not meet diapering needs resulting in diaper rash and facility does not provide clean and sanitary environment. Therefore, the preponderance of evidence standard has been met, the allegations are found to be Substantiated. California Code of Regulations, Title 22, 101223(a)(3) Personal Rights and 101212(d)(1) Reporting Requirements is being cited on the attached LIC 9099D.

This report cites a Type A violation and shall be provided to parents/guardians of children currently in enrolled and to parents/guardians of children newly enrolled at the facility during the next 12 months. Parents/guardians must sign Form LIC9224 to be kept in each child's file. Exit interview was conducted with Director Rebekah Bay. Director would like to be referred to the Technical Support Program (TSP) for consultation. Notice of Site Visit was posted during the visit, failure to post will result in civil penalties of $100. Appeal rights were provided and explained.
SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Carmen Odom
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 06-CC-20220620101702
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: GRACE HARBOR CHURCH AND SCHOOL
FACILITY NUMBER: 300606476
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/26/2022
Section Cited
CCR
101416.5(a)(b)
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101416.5(a)(b)- Staff-Infant Ratio a) In addition to Sections 101216.3 (c), (e), (g) and (h), and notwithstanding Sections 101216.3, (a), (b), (d) and (f), the following shall apply:(b) There shall be a ratio of one teacher for every four infants in attendance. This requirement is not met as evidenced by:
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Director stated as of July 2022 they are in charge of creating the staff schedules to make sure that the facility is always in ratio. Director stated they have reviewed staff-child ratio with staff in May and June of 2022. Director stated they will review staff-child ratio on 9/1/22. Director will submit written plan of correction in 24 hours.
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Based on interviews with staff, on 5/27/22 S4 was alone with 6 infants in the toddler room for 10 minutes. This poses an immediate risk to the health and safety of the children in care.
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Type A
08/26/2022
Section Cited
CCR
101428(b)(2)
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101428 Infant Care Personal Services (b) The infant shall be kept clean and dry at all times. (2) Each infant's clothing and diapers shall be changed as often as necessary to ensure that the infant is clean and dry at all times. This requirement is not met as evidenced by:
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Director stated they have recently added white boards in the infant classroom where staff can view when infants have fed and changed. Director stated they will review infant changing and procedure at the in service meeting on 9/1/22. Director will submit written plan of correction in 24 hours.
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Based on observations, interviews and records reviewed S2 did not change the infant’s diapers with frequency to maintain a clean and dry diaper at all times, also causing for children’s diaper rash. This poses an immediate risk to the health and safety 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.
SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Carmen Odom
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 06-CC-20220620101702
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: GRACE HARBOR CHURCH AND SCHOOL
FACILITY NUMBER: 300606476
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/26/2022
Section Cited
CCR
101238(a)
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101238 Building and Grounds (a) The child care center shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children, employees and visitors. This requirement is not met as evidenced by:
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Director stated June of 2022 the carpet were cleaned, staff have condcuted deep cleaning and staff wear slippers in the infant classroom. In the in service meeting staff will be reminded to clean and disinfect on a daily basis. Director stated they will also send weekly reminders to clean and disinfect their classrooms.
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Based on observations and interviews, staff do not wear booties inside the infant classroom, and facility was not properly disinfected in which it caused multiple cases of hand, foot, and mouth disease. This poses a potential health and safety of the children’s 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.
SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Carmen Odom
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5