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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300611137
Report Date: 01/22/2020
Date Signed: 01/22/2020 09:15:36 AM

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:BARBUTO, SALLY ANNFACILITY NUMBER:
300611137
ADMINISTRATOR:BARBUTO, SALLY ANNFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 525-8056
CITY:FULLERTONSTATE: CAZIP CODE:
92832
CAPACITY:14CENSUS: 6DATE:
01/22/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Sally Ann Barbuto, LicenseeTIME COMPLETED:
09:45 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Joel Enciso, Yesenia Villa and Carmen Odom conducted an unannounced case management inspection to obtain the licensee's signatures for an unannounced annual visit that was conducted by LPA Villa and LPA Enciso on 01/10/20. Signatures at the time of the annual visit were not obtained due to computer system issues (consistency check). LPA Villa and LPA Enciso toured the facility with the licensee the areas defined in the facility sketch as accessible to children. Present during the visit was the Licensee and her assistant son Keith Cangiarella caring for 6 children. A review of the Facility Personnel Report Summary on this date indicated that all facility residents, staff or other individuals who require caregiver background checks did receive criminal record and child abuse index clearance or exemptions.

During this visit LPAs were able to obtain electronic signatures on seven out of eight pages of the report due to computer system issues. The Licensee was provided with copies of her report on this day and hand signatures were obtained by the Licensee. LPAs provided a copy of an LIC9224 to the licensee and the form procedure was explained. The Licensee was instructed to provide this form to all parents for the next twelve months and obtain signatures. The form must be kept in the childrens records. Failure to maintain in the children's records will result in a $100.00 civil penalty fee.

An exit interview was conducted with the Licensee and a copy of the report was provided. The licensee was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights. The notice of site visit must be posted for 30 days. Failure to post will result in civil penalties of $100 LPAs informed the licensee of how to access regulations and forms from CCLD website. www.ccld.ca.gov or myccl.ca.gov. End of report.
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen OdomTELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2020
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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