304206496-5-17-2023-06-CC-ASIA-CRWTF7-20230517144103

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304206496
Report Date: 05/17/2023
Date Signed: 05/17/2023 02:41:28 PM

Document Has Been Signed on 05/17/2023 02:41 PM - 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 CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME:	WITH, SANDY		FACILITY NUMBER:	304206496
ADMINISTRATOR:	WITH, SANDY		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(949) 581-8931
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY:	14	CENSUS: 6	DATE:	05/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:23 PM
MET WITH:	Sandy With		TIME COMPLETED:	03:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On May 17 of 2023 at 12:23 pm, Licensing Program Analyst (LPA) A. Silva conducted an unannounced Required – 1 Year inspection assisted by licensee Sandy With. Upon arrival, the licensee had 6 clients in care, including 2 infants and 4 preschool children. An on-site Facility Personnel Report Summary review showed that all facility residents, staff, or other individuals who require background checks have received criminal record and child abuse index clearances or exemptions. 2 adults, including the licensee currently live in the home, according to the licensee. INDOOR INSPECTION. The LPA inspected the indoor FCCH (family child care home are) area identified in the Facility Sketch LIC999 and areas accessible to clients. Off-limits areas were inaccessible to clients in care by means of child gates and safety locks, at the time of inspection. The facility was equipped with working carbon monoxide and smoke detectors, working telephone service, and at least one fire extinguisher that meets statutory and State Fire Marshall standards. The licensee agrees to maintain telephone service in the home when clients are in care. The fireplace is covered with a plexiglass and a screen over it. The licensee stated that there are no firearms and/or other dangerous weapons in the facility; none were observed during the inspection. Detergents, cleaning compounds, medicines, and other items that could pose a danger if readily available were inaccessible to clients in care. No poisons or other items that could pose a danger to clients were observed during the inspection. Clients nap on mats. ON-SITE FOOD PREPARATION: The licensee provides breakfast, snacks and lunch to the children. At the time of inspection, food prep areas were clean and sanitary, and food was properly stored. Filtered drinking water is available to clients in care. The LPA observed that the facility’s floors, equipment, furniture, and clients’ bathrooms were clean and in good repair.

SUPERVISOR'S NAME: Patricia Magana	TELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Archibaldo Silva	TELEPHONE: (510) 504-4954
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: WITH, SANDY	FACILITY NUMBER: 304206496
	VISIT DATE: 05/17/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

809 page 2

OUTDOOR INSPECTION: The playground was enclosed by a fence. The outdoor equipment and toys were in good repair and free of sharp edges. At the time of inspection, the surface of the outdoor activity area was well-maintained and free of any observable hazards. The jacuzzi is off limits and locked.

PERSONNEL RECORDS: The LPA reviewed personnel files. The licensee’s mandated expired in 2019 and the CPR is current until 3/9/25.

CHILDRENS’ RECORDS: The licensee has a current roster of clients. The LPA reviewed 5 files of children who were present during the inspection. The infant files did not have the LIC9227 Individual Infant Sleeping Plan. The licensee stated she thought the sleep logs was all she needed (see 809D). The 15-minute check logs for two infants were available for review.

The Incidental Medical Services (IMS) policy was discussed. A link to PIN 22-02-CCP was provided here: PIN 22-02-CCP: Best Practices Related to the Provision of Incidental Medical Services in Child Care Centers and Family Child. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to the publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

The licensee understands that he or she shall be present in the home and shall ensure that children in care are supervised at all times. When circumstances require the licensee to be temporarily absent from the home, the licensee shall arrange for a qualified substitute adult to care for and supervise the children during his/her absence [A qualified substitute adult is an adult that has criminal record and child abuse index clearances, immunizations, and current Pediatric CPR/First Aid and Mandated Reporter training]. Temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day, in accordance with Section 102417 of the California Code of Regulations. The licensee understands that children are not to be left alone in parked vehicles.

SUPERVISOR'S NAME: Patricia Magana	TELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Archibaldo Silva	TELEPHONE: (510) 504-4954
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

LIC809 (FAS) - (06/04)

Page: 2 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: WITH, SANDY	FACILITY NUMBER: 304206496
	VISIT DATE: 05/17/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

809 page 3

The licensee understands that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption prior to the initial presence in a licensed child care facility. Violation of this requirement will result in a citation of a deficiency and civil penalties of one hundred dollars ($100) per violation per day for a maximum of five (5) days. Subsequent violations within a twelve (12) month period will result in a civil penalty of one hundred dollars ($100) per violation per day for a maximum of thirty (30) days in accordance with Section 1596.871 of the Health and Safety Code.

The licensee understands that a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year, in accordance with Section 1597.622 of the Health and Safety Code.

The licensee understands it is his or her responsibility to review the Provider Information Notices (PIN) found on the CCLD website below. If not yet registered, the licensee agrees to register to receive quarterly updates via email at childcareadvocatesprogram@dss.ca.gov or online at https://cdss.ca.gov/inforesources/community-care-licensing/subscribe

The LPA discussed the following resources with the licensee:
US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514- 0383 (TTY)
Commonly Asked Questions about Child Care Centers and the ADA link: http://www.ada.gov/childqanda.htm
CaSocialService YouTube Guardian Webinar “All Providers Webinar 12/20/22” link https://youtu.be/WNc1kYmlW9s
Guardian information link: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian

SUPERVISOR'S NAME: Patricia Magana	TELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Archibaldo Silva	TELEPHONE: (510) 504-4954
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

LIC809 (FAS) - (06/04)

Page: 3 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: WITH, SANDY	FACILITY NUMBER: 304206496
	VISIT DATE: 05/17/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

809 page 4
CCLD link: www.cdss.ca.gov/inforesources/community-care-licensing
CPSC (United States Consumer Product Safety Commission) link: https://www.cpsc.gov/

LPA reviewed the following safe sleep best practices with the licensee:
Always place infants 12 months and younger on their backs to sleep
Use only a tight-fitting sheet on the crib or play yard mattress
Do not hang any items from the crib or above the crib
Keep all items including blankets, pillows, and stuffed dolls out of the crib or play yard
Pacifiers may be used only if they do not have items attached to them and there is no recall
Infants should not be swaddled or have any items covering them while sleeping
The temperature of the room should be comfortable enough for a lightly clothed adult
Complete Individual Sleeping Plan LIC9227 for infants 12 months and younger
Conduct and document the 15-minute checks for all infants under 24 months
CDSS Safe Sleep link: https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep.

The facility was NOT in compliance. Violations of the California Code of Regulations, Title 22, Division 12 were observed, discussed, and cited at the time of the visit. The following violations of the California Code of Regulations, Title 22; Division 12, were observed and cited today: 1596.8662(b)(1) Administration of Child Day Care Licensing and 102425(c) Infant Safe Sleep

SUPERVISOR'S NAME: Patricia Magana	TELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Archibaldo Silva	TELEPHONE: (510) 504-4954
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

LIC809 (FAS) - (06/04)

Page: 4 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: WITH, SANDY	FACILITY NUMBER: 304206496
	VISIT DATE: 05/17/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

809 page 5

The LPA conducted an exit interview and reviewed the report with the licensee. The “Notice of Site Visit” was posted and the licensee is aware that it shall remain posted for 30 days. The Appeal Rights were explained. The licensee received a copy of the Appeal Rights (LIC 9058 01/16), 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. First-level appeals should be sent to the Regional Manager to the address listed above.

To improve the quality and value of the inspection process, a survey will be sent to the email address provided. Please complete the survey to share your inspection experience. If you have any questions regarding the process or tools used during the inspection, email them to inspectionprocess@dss.ca.gov. For more information about the inspection, its tools, and methods visit www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.
End of Report.

SUPERVISOR'S NAME: Patricia Magana	TELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Archibaldo Silva	TELEPHONE: (510) 504-4954
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

LIC809 (FAS) - (06/04)

Page: 5 of 6

Document Has Been Signed on 05/17/2023 02:41 PM - 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 CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: WITH, SANDY	FACILITY NUMBER: 304206496
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.8662(b)(1)

Administration of Child Day Care Licensing

(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and file review, the licensee did not comply with the section cited above in 2 out of 2 staff who need a mandated reporter certificate, which poses/posed a potential health, safety or personal rights risk to persons in care.The licensee stated she forgot to about the mandated reporter.
	POC Due Date: 05/29/2023
	Plan of Correction
1 2 3 4	The licensee stated that she and her assistant will complete a mandated reporter training and provide proof of correction by the due date via archibaldo.silva@dss.ca.gov

Type B

Section Cited

CCR

102425(c)

Infant Safe Sleep

An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and records review, the licensee did not comply with the section cited above in 1 out of 1 infatns, which poses/posed a potential health, safety or personal rights risk to persons in care. The licensee stated she did not know shee nedded an LIC 09227 for the infants.
	POC Due Date: 05/29/2023
	Plan of Correction
1 2 3 4	The licensee stated she will obtain complete copies of the LIC 9227 for all infants under 12 months old and provide proof of correction by the due date at archibaldo.silva@dss.ca.gov

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: Patricia Magana	TELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Archibaldo Silva	TELEPHONE: (510) 504-4954
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

LIC809 (FAS) - (06/04)

Page: 6 of 6