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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304270170
Report Date: 05/19/2022
Date Signed: 05/19/2022 11:22:15 AM


Document Has Been Signed on 05/19/2022 11:22 AM - It Cannot Be Edited

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:CATALYST KIDS-TUSTIN RANCHFACILITY NUMBER:
304270170
ADMINISTRATOR:DANG, CATHYFACILITY TYPE:
840
ADDRESS:12950 ROBINSON DRIVETELEPHONE:
(714) 573-9256
CITY:TUSTINSTATE: CAZIP CODE:
92782
CAPACITY:105CENSUS: 0DATE:
05/19/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Vi Khy - TeacherTIME COMPLETED:
11:35 AM
NARRATIVE
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Licensing Program Analyst Carmen Odom conducted an unannounced Case Management visit. LPA met with Staff member Vi Khy, Director was on vacation, to discuss the Lead Sampling Testing conducted on 04/23/22. Staff was advised on 05/16/22 that the Lead Sample Report was to be posted. LPA confirmed that Staff had posted the Lead Sample Report.

Staff stated the outlet with high levels of Lead are inoperable. They have made the kitchen faucet/outlet that tested with high levels of Lead inoperable with plastic bag wrapped around the faucet, tapped all around and a sign posted “do not use”. The outlet is in room#1 temporarily closed off until the they replace and retest the kitchen faucet. Source of drinking water is 2 large igloo water jugs; the jugs are refilled from outlets in room#2 that tested negative for Lead. Staff stated they have ordered the replacement faucet, when the replacement faucet arrives, they will have it retested for Lead.

Based on LPAs record reviews the following violation was observed and is being cited in accordance with California Code of Regulations Title 22, Division 12, Chapter 3, Section 101238(a) Buildings and Grounds is being cited on the attached LIC 809D.

Exit interview conducted and report was reviewed with the facility representative Vi Khy. A notice of site visit was given and must remain posted for 30 days.



Appeal Rights were explained. The Licensee was provided a copy of appeal rights (LIC 9058 01/16) and 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.
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen OdomTELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2022
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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Document Has Been Signed on 05/19/2022 11:22 AM - 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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868


FACILITY NAME: CATALYST KIDS-TUSTIN RANCH
FACILITY NUMBER: 304270170

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
05/19/2022
Section Cited

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101238(a) Buildings and Grounds. The childcare 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 was not met as evidenced by:
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Based on facility Lead sampling tests it was discovered that kitchen faucet/outlet in Rm 1 had high level of lead. This poses a potential risk to the health of 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.
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen OdomTELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2022
LIC809 (FAS) - (06/04)
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