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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304312113
Report Date: 11/09/2022
Date Signed: 11/09/2022 09:34:15 AM


Document Has Been Signed on 11/09/2022 09:34 AM - 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:AYERS, PAMELAFACILITY NUMBER:
304312113
ADMINISTRATOR:AYERS, PAMELAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 895-9585
CITY:CYPRESSSTATE: CAZIP CODE:
90630
CAPACITY:14CENSUS: 8DATE:
11/09/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:46 AM
MET WITH:Pamela Ayer, LicenseeTIME COMPLETED:
09:45 AM
NARRATIVE
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On 11/09/2022 Licensing Program Analyst (LPA), Stella Gutierrez made an unannounced facility inspection for a case management. Upon arrival LPA was met by Licensee, Pamela Ayers was explained the reason for todays visit. LPA observed Licensee and assistant caring for 08 children (2 Infants and 6 preschool children).

A review of the Facility Personnel Report Summary conducted on 11/09/2022 indicates all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.


On 09/15/2022 LPA, Gutierrez made an unannounced visit to the facility on 09/15/2022. During the visit LPA interviewed Staff #1 regarding the appropriate discipline that used at the facility. Staff #1 stated that children are put in time out at the facility for 10-15 minutes by placing them by the wall outside in the on limits back yard area. This violates the personal rights of the children in care.

Based on the statement provided to LPA on 09/15/2022 a Type B deficiency will be cited in accordance to Tittle 22, Division 12, Chapter 1, Article 06 102423 (a) (1).

Exit interview conducted and report was reviewed with the licensee, Pamela Ayers. Appeal Rights 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.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Stella GutierrezTELEPHONE: (714) 293-5262
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2022
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 11/09/2022 09:34 AM - 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: AYERS, PAMELA
FACILITY NUMBER: 304312113

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/09/2022
Section Cited

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Personal Rights 102423 (a) Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to, the following: (1) To be treated with dignity in his/her
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 personal relationship with staff and other persons.
This regulation was not met as evidence by statement provided by Staff #1 that the children receive a time out at the facility by being place outside by gate area for 10-15 minutes while in care. This poses a risk to the children in care.
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LPA provided the Childcare care licensing E-learning module today for licensee to utilize while caring for children.

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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) 703-2821
LICENSING EVALUATOR NAME: Stella GutierrezTELEPHONE: (714) 293-5262
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2022
LIC809 (FAS) - (06/04)
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