<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304270170
Report Date: 08/23/2019
Date Signed: 08/23/2019 03:23:07 PM

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:TUSTIN RANCH SCHOOL AGE CHILD DEVELOPMENT CENTERFACILITY NUMBER:
304270170
ADMINISTRATOR:DAWOD, KARIEFACILITY TYPE:
840
ADDRESS:12950 ROBINSON DRIVETELEPHONE:
(714) 573-9256
CITY:TUSTINSTATE: CAZIP CODE:
92782
CAPACITY:105CENSUS: 16DATE:
08/23/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Karie DawodTIME COMPLETED:
03:45 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
Licensing Program Analyst (LPA) Hawkins conducted a case management visit at the facility due to an incident report that was reported to the licensing office on 8/9/19. According to the unusual incident report, on 8/6/19 Child #1 reported to Teacher #1 that his ankle was hurting from jumping on a trampoline during a filed trip to Rock N' Jump (trampoline jump house). Facility staff provided first aid to the child and contacted parent who then took child to receive medical attention . The director toured the inside and outside of the facility including the playground equipment with LPA. There were a total of 16 school age children observed playing on the playground with 9 staff including the director. 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.

LPA interviewed 1 staff and 1 child. Director stated that the incident occurred during a field trip away from the licensed facility and Child #1 reported the same. Appropriate care of child was provided by staff after learning of the accident.

No deficiencies were cited for this case management inspection.

An exit interview was conducted with the Director.

Report was reviewed and discussed. The licensee was provided a copy of their appeal rights and their signature on this form acknowledges receipt of these rights. The first level appeal is to regional manager, address is above on the report. 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. This report is to be on file and accessible for public review at the facility for at least 3 years.

SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Sherene HawkinsTELEPHONE: (949) 466-1624
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2019
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 1