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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304270976
Report Date: 02/23/2021
Date Signed: 02/23/2021 05:35:54 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:KIDS ADVENTURE LEARNING CENTERFACILITY NUMBER:
304270976
ADMINISTRATOR:ORTIZ, DELMYFACILITY TYPE:
840
ADDRESS:1834 VALENCIATELEPHONE:
(714) 525-7377
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY:17CENSUS: 3DATE:
02/23/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Assistant Director Susan ContrerasTIME COMPLETED:
05:32 PM
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Tele Inspection-Covid 19

Licensing Program Analyst (LPA) Barajas conducted an unannounced case management inspection to deliver findings in response to a self reported unusual incident that occurred on 02/05/2020 and was received in our office on 02/12/2020, and phone call on 02/13/2020. This is a continuation of the investigation initiated on 02/26/2020 and 03/09/2020. The facility reported a child sustained an injury to the chin, injuring mouth and bottom teeth.

During today’s investigation LPA toured the facility inside and outside and observed 3 school age children and 1 school age staff member Francia De la Riva in green room. A review of staff 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.

During the investigation LPA interviewed Director, 2 Staff, 2 children, a parent, took pictures, requested medical, dental documents, requested facility documents and conducted to physical plant visits.

The inspection was conducted in response to an Unusual Incident Report received on 02/12/2020 but occurring on 02/05/2020 in which child #2 was running and fell in playground and injured bottom teeth and lip. Staff #1 witnessed the fall and attended to the child's injury. At that time the parent of child #2 was contacted via phone and injury was communicated to parent. Staff #1 communicated the injury to staff #2. The parent of child #2 was not followed up with seriousness of injury, and it was discovered by parent upon arrival that child did not stop bleeding and parent took child to seek medical attention. Director did not inform Licensing Department via phone until 02/13/2020. This incident was not reported to licensing in a timely fashion. An inspection was conducted on 02/26/2020 and 03/09/2020, to investigate into this unusual incident.

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SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 743-5149
LICENSING EVALUATOR NAME: Leonor BarajasTELEPHONE: (714) 292-8628
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2021
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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: KIDS ADVENTURE LEARNING CENTER
FACILITY NUMBER: 304270976
VISIT DATE: 02/23/2021
NARRATIVE
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During the investigation a parent, staff and children related to the reported unusual incident were interviewed, a physical plant inspection was conducted, LPA took pictures of playground grass/turf and census of children was taken and obtained declaration letters. LPA was able to determine that the facility did not follow up with the family of child #2 regarding the injury nor reported this incident to licensing as required of the facility. LPA was also able to determine grass/turf in playground was uneven, was not cushioned, had holes, and was not safe or incompliance with Title 22 regulations. Therefore, facility will be cited for Buildings and Grounds, Outdoor Activity Space and Reporting Requirements California Code of Regulations , (Title 22, Division & Chapter) is being cited on the attached LIC 809D,

101238.2(e )Outdoor Activity Space: (e) As a condition of licensure, the areas around and under high climbing equipment, swings, slides and other similar equipment shall be cushioned with material that absorbs falls.

101238(a) Buildings and Grounds: (a)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.

101212(d)(1)(B) Reporting Requirements: (d) Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event. (1) Events reported shall include the following: (B)Any injury to any child that requires medical treatment.

Exit interview was conducted with Director Delmy Ortiz via Tele-Inspection. Report was read to Director. A copy of the report along with Appeal Rights will be emailed to Director with a Read Receipt to acknowledge report was received. If Read Receipt is not functional, Director will respond to email stating “I have read and received the report, I acknowledge receipt.” LIC 9099 will also be mailed if those options are not available.

End of Report.

SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 743-5149
LICENSING EVALUATOR NAME: Leonor BarajasTELEPHONE: (714) 292-8628
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: KIDS ADVENTURE LEARNING CENTER
FACILITY NUMBER: 304270976
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/26/2021
Section Cited

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101238.2(e )Outdoor Activity Space: (e) As a condition of licensure, the areas around and under high climbing equipment, swings, slides and other similar equipment shall be cushioned with material that absorbs falls. This requirement is not met as evidenced by:
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Based on LPA Barajas observation and interviews conducted with 3 staff, parent, 2 children facility inspection and pictures taken, there were holes in turf grass and soil was not even, tripping hazard, not enough cushioning. This poses a potential immediate risk to the health and safety of children in care
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Type B
02/26/2021
Section Cited

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101238(a) Buildings and Grounds: (a)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 is not met as evidenced by:
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Baesd on LPA Barajas observation and interviews with 3 staff, a parent, 2 children, playground inspection and pictures taken. Playground was observed not to be in good repair, LPA took pictures of ripped turf grass, uneven soil next to playground, taped and untaped turf. This poses a potential immediate risk to the health and safety 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: Patricia MaganaTELEPHONE: (714) 743-5149
LICENSING EVALUATOR NAME: Leonor BarajasTELEPHONE: (714) 292-8628
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: KIDS ADVENTURE LEARNING CENTER
FACILITY NUMBER: 304270976
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/26/2021
Section Cited

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101212(d)(1)(B)Reporting Requirements: (d) Upon the occurrence, during the operation of the child care center...(d)(1) below, a report shall be made to the Dept by telephone or fax within the Dept next working day... Dept within seven days following the occurrence of such event...Any injury to any child that requires medical treatment.This requirement is not met as evidenced by:
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Based on records reviewed and LPA Barajas interviewed with Director. Director disclosed was not aware had to report UIR to Dept by next business day. LPA received mailed UIR on 02/12/2020 incident was on 02/05/2020, Director contacted dept on 02/13/2020 via phone. This poses a potential immediate risk to the health and safety 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: Patricia MaganaTELEPHONE: (714) 743-5149
LICENSING EVALUATOR NAME: Leonor BarajasTELEPHONE: (714) 292-8628
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4