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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304270866
Report Date: 05/16/2023
Date Signed: 05/16/2023 12:29:30 PM


Document Has Been Signed on 05/16/2023 12:29 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
ORANGE CO CHILD CARE, 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) 210-6041
CITY:TUSTINSTATE: CAZIP CODE:
92782
CAPACITY:112CENSUS: 90DATE:
05/16/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Director Christine MitchellTIME COMPLETED:
12:45 PM
NARRATIVE
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On 05/16/2023, A case management inspection was conducted today by Licensing Program Analyst (LPA), Chan who met with the Director, Christine Mitchell. A self-reported incident by the facility was received at the regional office on 5/03/2023 which stated that child #1 (C1) was in a non-operating Black Room due to low ratio and left unsupervised for 10 minutes.

Upon arrival there were 10 staff present and 90 children in care. 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 Director, and 2 staff (Staff #1 or S1 and Staff #2 or S2) present at the time the incident happened. LPA obtained a copy of the children roster, Children Sign in and sign out sheet for week of 05/01/2023 and Personnel Summary Report. The S1 realized child was in the Black Room when staff went and saw toys were out. Director and S1 reviewed video footage for Black Room and found child in the Black Room was unsupervised for 10 minutes.

Based on the information gathered from the interviews conducted, observation and records reviews, it was determined that C1 was in the Black Room unsupervised for about 10 minutes at 11:32am. The Black Room is connected to the White Room by a Jack and Jill restroom. The Black Room on 05/02/2023 was not being utilized due to low ratio and low number of teachers present.

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.

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SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Anna Francesca ChanTELEPHONE: (818) 216-9775
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: SALVATION ARMY, TUSTIN RANCH-CREATOR'S CORNER, THE
FACILITY NUMBER: 304270866
VISIT DATE: 05/16/2023
NARRATIVE
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LPA Chan informed director Christine Mitchell that this report dated 05/16/2023 for 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 Chan informed the director Christine Mitchell to provide a copy of this licensing report dated 05/16/2023 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 Christine Mitchell. 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.

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SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Anna Francesca ChanTELEPHONE: (818) 216-9775
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/16/2023 12:29 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
ORANGE CO CHILD CARE, 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: 05/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/16/2023
Section Cited
CCR
101229(a)(1)

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Responsibility for Providing Care and Supervision section 101229(a)(1)
No child(ren) shall be left without the supervision, including visual observation, of a teacher at any time ...

This requirement is not met as evidenced by:
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The director stated that they did an emergency staff meeting regarding Supervision following this incident. A copy of the meeting agenda with staff signatures will be provided to the LPA at the end of the visit on 05/16/2023
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Based on observation of video footage, record reviews and interviews, C1 was unsupervised at the vacant Black Room for about 10 minutes. Staff were not aware child went to the Black Room . 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: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Anna Francesca ChanTELEPHONE: (818) 216-9775
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2023
LIC809 (FAS) - (06/04)
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