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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304270866
Report Date: 09/20/2019
Date Signed: 09/20/2019 12:16:16 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:SALVATION ARMY, TUSTIN RANCH-CREATOR'S CORNER, THEFACILITY NUMBER:
304270866
ADMINISTRATOR:MITCHELL, CHRISTINEFACILITY TYPE:
850
ADDRESS:10200 PIONEER ROADTELEPHONE:
(714) 210-6040
CITY:TUSTINSTATE: CAZIP CODE:
92782
CAPACITY:112CENSUS: 96DATE:
09/20/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Christine MitchellTIME COMPLETED:
12:45 PM
NARRATIVE
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A case management inspection was conducted at this Preschool by Licensing Program Analyst (LPA) Hawkins.
During todays inspection LPA toured the facility inside and outside and observed a total census of 96 preschool children with 14 preschool staff. There were 65 preschoolers, and 10 preschool staff in 5 classrooms ( brown, red, blue, yellow, green), and 31 children, 4 preschool staff, and 1 staff (outside vendor) observed playing on the playground. A review of staff criminal clearance records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.
LPA met with director Christine Mitchell and discussed the unusual incident report in which Child #1 (See Confidential Names List LIC811) was left unattended (no supervision) in the bathroom for approximately 20 minutes during afternoon transition time from playground to classroom. The facility representative left voice messages regarding the incident on 9/10/19, and 9/11/19. LPA Corral spoke with representative on 9/12/19 and incident was reported to the licensing office.

During investigation, information was gathered. Based on the interviews conducted during the investigation and the information obtained, it was determined that Child#1 was left unsupervised in the children's bathroom for an extended period of time.

The facility was not in compliance and violation of the California Code of Regulations, Title 22, Division 12 Section 101229(a)(1) was observed, discussed and cited at the time of the visit. (See LIC 809-D for specific deficiencies).

An exit Interview was conducted. Director was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. Director 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. Failure to post Type A reports for 30 days will result in a civil penalty of $100.00 . ****Continued on page 2
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Sherene HawkinsTELEPHONE: (949) 466-1624
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2019
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 3
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: SALVATION ARMY, TUSTIN RANCH-CREATOR'S CORNER, THE
FACILITY NUMBER: 304270866
VISIT DATE: 09/20/2019
NARRATIVE
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“Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. Licensee shall have LIC 9224 (Acknowledgement of Receipt) signed and kept in each child's file.
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Sherene HawkinsTELEPHONE: (949) 466-1624
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2019
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: SALVATION ARMY, TUSTIN RANCH-CREATOR'S CORNER, THE
FACILITY NUMBER: 304270866
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/20/2019
Section Cited

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101229 Responsibility for Providing Care and Supervision; (a) The licensee shall provide care and supervision as necessary to meet the children's needs.(1) No child(ren) shall be left without the supervision of a teacher at any time...(1)Supervision shall include visual observation. This requirement was not met as evidenced by Child #1 being left unattended
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without supervision in the "Blue restroom" for approximately 20 minutes". This posses an immediate health and safety risk to the children in care.
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existing and new procedures regarding monitoring afternoon attendance and head counts. Director stated that dicipline action was taken for staff involved according to the facility's plan of operation. Director provided updated procdures, agenda of training, and staff log of training during visit. Deficiences were cleared during visit.

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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: Sherene HawkinsTELEPHONE: (949) 466-1624
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2019
LIC809 (FAS) - (06/04)
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