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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304270834
Report Date: 04/11/2023
Date Signed: 04/11/2023 03:57:54 PM


Document Has Been Signed on 04/11/2023 03:57 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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868



FACILITY NAME:CATALYST KIDS-MYFORDFACILITY NUMBER:
304270834
ADMINISTRATOR:VILLARREAL, SITIFACILITY TYPE:
840
ADDRESS:3181 TREVINO DRIVETELEPHONE:
(714) 508-1480
CITY:IRVINESTATE: CAZIP CODE:
92602
CAPACITY:105CENSUS: 30DATE:
04/11/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Siti Villarreal - Site SupervisorTIME COMPLETED:
04:15 PM
NARRATIVE
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A case management inspection was conducted today by Licensing Program Analyst (LPA), Odom who met with the Director, Siti Villarreal. A self-report incident by the facility was received at the regional office on 3/29/23 which stated that child #1 (C1) was left in the outdoor playground restroom unsupervised for 5-10 seconds.

Upon arrival there were 2 staff present without any children in care. Director stated children begin to arrive at 2:37pm. At 2:42pm census was taken today and there was a total of 30 school age children with a total of 3 staff members. A review of criminal record clearances indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

During this investigation, LPA interviewed 4 staff, 1 child and obtained a copy of the children roster, personnel report, and took pictures. From the interviews conducted it was discovered on 3/28/22 at around 4:20pm during outdoor play right before clean-up time to head into the classroom, C1 told Staff #1 (S1) they were going to the restroom. S1 notified the rest of the staff that C1 had gone to the restroom via walkie talkie. While C1 was in the outdoor restroom located 28 feet from the basketball court the children cleaned up, headed back into the classroom with S1. Less than 1 minute after S1 walked inside the classroom with all the children, C1 appeared in the classroom alone announcing that C1 was left alone in the restroom. Staff #3 (S3) stated when they spoke with S1 regarding the incident S1 disclosed they failed to conduct a head count upon entering the classroom. LPA interviewed C1 and C1 disclosed staff forgot C1 was in the restroom.

Based on the information gathered from the interviews conducted, observation and records reviewed. It was determined that C1 was left in the restroom unsupervised for about 1-2 minutes.

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SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen OdomTELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2023
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 04/11/2023 03:57 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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868


FACILITY NAME: CATALYST KIDS-MYFORD
FACILITY NUMBER: 304270834

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/11/2023
Section Cited

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Care and Supervision 101229(a)(1): No child(ren) shall be left without the supervision, including visual observation, of a teacher at any time except as specified in sections 101216.2(e)(1) and 101230(c)(1). This requirement is not met as evidenced by:
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Director stated they did conduct a staff training on 3/30/23 with all staff and review supervision policies. They have also implemented face to name head count. Director will submit a written POC to licensing depratment by 4/12/23.
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Based on observation and interviews, C1 was left unsupervised at the outdoor playground restroom for 2 minutes. Staff were not aware child was left outside until C1 appeared in the classroom. This is an immediate risk to the health and safety of the 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: 04/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2023
LIC809 (FAS) - (06/04)
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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-MYFORD
FACILITY NUMBER: 304270834
VISIT DATE: 04/11/2023
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The facility was not in compliance of the California Code of Regulations, Title 22, Division 12. The following citation Responsibility for Providing Care and Supervision section 101229(a)(1) was issued today on the attached LIC 809D.

LPA Odom informed director Siti Villarreal that this report dated 4/11/2023 document 1 Type A citation which shall be posted for 30 consecutive days as there is immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Odom informed the director Siti Villarreal to provide a copy of this licensing report dated 4/11/2023 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Exit interview conducted and report was reviewed with the director Siti Villarreal. A notice of site visit was given and must remain posted for 30 days.



Appeal Rights and deficiencies were discussed. The facility representative was provided a copy of their appeal rights (LIC 9058) 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.
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen OdomTELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
LIC809 (FAS) - (06/04)
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