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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300613936
Report Date: 07/25/2019
Date Signed: 07/25/2019 10:36:15 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:MISSION VIEJO CHRISTIAN KIDS CLUBFACILITY NUMBER:
300613936
ADMINISTRATOR:SWEETSER, JOHNFACILITY TYPE:
840
ADDRESS:27192 JERONIMO ROADTELEPHONE:
(949) 465-1954
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92692
CAPACITY:175CENSUS: 113DATE:
07/25/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:DirectorTIME COMPLETED:
11:00 AM
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A case management inspection was conducted today by Licensing Program Analyst (LPA), Mahnaz (Nancy) Malek who met with the director, John Sweetser. Census was taken and there were a total of 113 school age children with 10 other staff on the outdoor area. Later on, children came to the facility for music activity during LPA's inspection.

LPA discussed the unusual incident report which was self reported to our office by the facility representative on 7/24/2019. LPA obtained and reviewed some documentation regarding the unusual incident. This unusual incident has been assigned to Investigator Ernestina Bellucco from Investigation Branch (IB) with our Department. Due to insufficient information available at this time, the reported incident needs further investigation.

The Notice of Site Visit was posted. Facility representative was informed that the Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100. The licensee was provided a copy of their appeal right (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Licensing office within 15 business days.

The facility representative was informed that they can refer to our Department website at www.ccld.ca.gov for obtaining the quarterly updates.

Exit interview was conducted. .

This report ends here.
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Mahnaz MalekTELEPHONE: (714) 703-2810
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2019
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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