304270591-10-14-2019-06-CC-SHAS-BGXP9B-20191014110651

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304270591
Report Date: 10/11/2019
Date Signed: 10/14/2019 11:06:58 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:	ALDERSGATE UNITED METHODIST CHURCH DAY CARE CENTER		FACILITY NUMBER:	304270591
ADMINISTRATOR:	KUSH, JACKIE		FACILITY TYPE:	840
ADDRESS:	1201 IRVINE BLVD.		TELEPHONE:	(714) 544-5510
CITY:	TUSTIN	STATE: CA	ZIP CODE:	92780
CAPACITY:	45	CENSUS: 0	DATE:	10/11/2019
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME BEGAN:	12:01 PM
MET WITH:	Cheyenne Cazares		TIME COMPLETED:	02:15 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	Licensing Program Analyst (LPA) Hawkins met with the director, Cheyenne Cazares, for a required annual visit. LPA toured the facility, including all activity/classroom areas, the isolation area, rest-rooms and outdoor play areas. There were no children present during today's inspection. LPA observed 3 staff members. A review of staff records on this date indicates that all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPA reviewed staffing ratios, health related services, including medications and first aid supplies, furniture, equipment, drinking water and food service provisions. LPA observed all required forms to be posted. Medications are stored in a cabinet inaccessible to children in care. Some first aid materials were available. There are smoke and carbon monoxide detectors are found in every classroom. There are adequate toys and equipment available for children. The rest-room was observed to be in working order. The facility provides AM and P.M. snack. When the school operates during break periods and summer break period, the school provides AM & PM and the children bring their own lunches. The program operates from 7:00a.m.- 6:00p.m. LPA reviewed the sign/in-sign/out sheet, children's and personnel records. At least one staff member present today have current Pediatric CPR and First Aid (exp. 2/21) throughout the day. LPA reviewed staff and children's files as well as LIC500 and children's roster. Children files were reviewed for identification/emergency information form (LIC 700) and was found to be complete. Staff files were reviewed for educational background/training/experience, health screening, and tuberculosis screening. Staff files were found to be complete. This facility provides Incidental Medical Services – IMS. Director states that there are no children currently requiring IMS services at this time. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. 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 publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm Continued on page 2.

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Sherene Hawkins	TELEPHONE: (949) 466-1624
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2019

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 2

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: ALDERSGATE UNITED METHODIST CHURCH DAY CARE CENTER	FACILITY NUMBER: 304270591
	VISIT DATE: 10/11/2019

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

Page 2
In the areas that were evaluated, no deficiencies were observed of the California Code of Regulations, Title 22, Division 12 at the time of the visit.

The facility representative was informed that Licensing Quarterly Updates are available at www.ccld.ca.gov . The facility representative may request to be added to an email list to receive a Quarterly Update by contacting the Child Care Advocate at childcareadvocatesprogram@dss.ca.gov

Information on the additional nutrition training, immunization requirements for children, and Health Schools Act (http://www.cdpr.ca.gov/docs/pestmgt/schoolipm.htm) were provided. The facility representative was informed, and website given, about the California Child Care Disaster Plan has been posted to the UCSF California Childcare Health Program website: cchp.ucsf.edu/content/disaster-preparedness Also provided was information about the E-Learning Modules available at https://ccld.childcarevideos.org A copy of the Nutritious Beverage Bill was provided to the facility representative.
A copy of the 2016 “A Child Care Providers Guild to Safe Sleep” was discussed with the facility representative, and website given below:
English: https//www.cdph.ca.gov/programs/SIDS/Doucments/SIDSchildcaresafesleep.pdf
Spanish: https//www.cdph.ca.gov/programs/SIDS/Doucments/ChildCareProvSleepSPAN2011.pdf

Director provided LPA with an updated Personnel Report (LIC 500); copy of the IMS plan

Documents/Information to be updated and returned to the Licensing Office
- Emergency Disaster Plan (LIC 610)
- Designation of Administrative Responsibility (LIC 308)
An exit interview was completed. The report was reviewed and discussed. The facility representative was provided a copy of their appeal rights (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 the “Notice of Site Visit” must be posted for 30 consecutive days. Failure to post will result in Civil Penalties of $100.00. The “Notice of Site Visit” must be posted on or adjacent to the door. Failure to post Type A reports for 30 day will result in a Civil Penalty of $100.00

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Sherene Hawkins	TELEPHONE: (949) 466-1624
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2019

LIC809 (FAS) - (06/04)

Page: 2 of 2