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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304312345
Report Date: 10/22/2019
Date Signed: 10/22/2019 11:42:52 AM

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:KISTLER, DEBORAH JEANFACILITY NUMBER:
304312345
ADMINISTRATOR:KISTLER, DEBORAH JEANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 754-4278
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY:14CENSUS: 6DATE:
10/22/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Deborah KistlerTIME COMPLETED:
12:10 PM
NARRATIVE
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An inspection was conducted at the facility by Licensing Program Analyst (LPA) Mila Quinto. The LPA toured the facility with licensee, Deborah Kistler. A review of adult records indicates that all facility residents, staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. There are presently four adults including the licensee and one child living in the home. An updated 279B was obtained during today's inspection. During today's inspection the home and grounds were toured, and the licensee was not operating within the licensed capacity. At 9:35am, census was taken and there were 4 infants and 2 preschool age children in care. Operating hours are 7:15 am - 5pm, Monday through Friday.

The floor plan was verified and no changes from previous visit. The off-limits areas were made inaccessible to children by means of baby gates. The outdoor area is free from hazards. Items which could pose a danger to children (detergents, cleaning compounds, and medications) were stored out of the reach of children. The licensee stated poisonous items are not stored on site, and none were observed during today's inspection. The home provides safe toys, equipment, and materials. During today's inspection each child was observed to have safe, healthful and comfortable accommodations, furnishings, and equipment. There is a working carbon monoxide detector, smoke detector, and fire extinguisher in the home that meet statutory and State Fire Marshall standards. The licensee has a current roster of children in care (obtained copy of roster). The facility has conducted an emergency drill within the past six months and log was verified. The licensee stated there are no firearms and/or other dangerous weapons in the home and none were observed during today's visit.

The licensee's pediatric CPR/First Aid Certificate expires on 8/01/2020. Licensee does not have proof of immunization against pertussis and measles and against influenza.
Children's records were reviewed and in compliance.
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Mila QuintoTELEPHONE: (714) 293-6471
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2019
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 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: KISTLER, DEBORAH JEAN
FACILITY NUMBER: 304312345
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/22/2019
Section Cited

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1596.8662(b)(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child care provider... or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement is not met as evidenced by:
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Based on observation and review, proof of completion of required mandated reporter training was not available for review during today's inspection. This poses a potential safety risk to children in care.
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Type B
11/22/2019
Section Cited

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 (a) (1) Commencing September 1, 2016, a person shall not be employed... day care home if he or she has not been immunized against influenza, pertussis, and measles...shall receive an influenza vaccination between August 1 and December 1 of each year.
This requirment is not met as eviddence by:
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Based on observation and reveiw, the licensee was unable to show proof of immunization/immunity against measles, pertussis and influenza. This poses a potential health risk to 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: Mila QuintoTELEPHONE: (714) 293-6471
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2019
LIC809 (FAS) - (06/04)
Page: 4 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: KISTLER, DEBORAH JEAN
FACILITY NUMBER: 304312345
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/22/2019
Section Cited

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Staffing Ratio and Capacity 102416.5(e) If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home as specified in subsections (b) and (c).
This Requirement is not met as evidenced by:
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Based on observation and interview, the licensee failed to ensure the maximum number of infants for whom care may be provided at any one time. LPA observed 4 infants and 2 preschool age children in home. Licensee did not have an assistant during this time. This poses an immediate health and safety risk to 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: Mila QuintoTELEPHONE: (714) 293-6471
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2019
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: KISTLER, DEBORAH JEAN
FACILITY NUMBER: 304312345
VISIT DATE: 10/22/2019
NARRATIVE
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Beginning March 31, 2018, Health and Safety Code 1596.8662 requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years, per A.B. 1207. Licensee has not completed the required mandated reporter training.
Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at http://www.ada.gov/childganda.htm.

LPA provided the licensees with the copy of Safe Sleep and Lead handout.
Licensee was advised on how to receive notifications for quarterly updates and provided with Child Care Advocate contact information: childcareadvocatesprogram@dss.ca.gov.

The following violations of the California Code of Regulations (CCR), Title 22; Division 12 Section 102416.5(e) Staffing Ratio and Capacity, Health and Safety 1596.8552(b)(1) training for mandated reporter and Health and Safety 1597.622(a)(1) Employee and Volunteer Immunization were observed and cited on the LIC 809D.

Reports citing Type A violations are to be provided to parents/guardians of children currently in enrolled and to parents/guardians of children newly enrolled at the facility during the next 12 months. Parents/guardians must sign Form LIC9224 to be kept in each child's file.

Inspection report reviewed and exit interview was conducted. Notice of Site Visit was posted during the visit. Facility representative 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. Appeal rights provided and explained. The licensee was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights. First level should be sent to the regional manager to the address listed above. Licensee was informed of how/where to access regulations and forms from CCLD website: www.ccld.ca.gov.

SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Mila QuintoTELEPHONE: (714) 293-6471
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2019
LIC809 (FAS) - (06/04)
Page: 2 of 4