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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304312345
Report Date: 10/29/2019
Date Signed: 10/29/2019 10:20:36 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: 4DATE:
10/29/2019
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Deborah Kistler, licenseeTIME COMPLETED:
10:45 AM
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This is a follow-up proof of correction inspection that was conducted by Licensing Program Analysts (LPA) Mila Quinto. LPA met with licensee, Deborah Kistler who guided the analyst on a tour of the facility. LPA observed 3 infants and 1 preschool children in care. The facility is operating within its licensed capacity and within compliance of staffing ratios. Present during today's inspection was licensee. A review of staff records on this date indicates that all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.

An initial unannounced random annual visit was conducted on 10/22/2019 and a LIC 809 was completed.
The following deficiencies that were previously cited on a LIC 809 dated 10/22/19 have been cleared:
1. LPA observed 3 infants and 1 preschool children. The facility is operating within its licensed capacity and within compliance of staffing ratios.
2. Licensee completed the mandated reporter training and provided copy of the certificate dated 10/28/2019.

LPA observed the Notice of Site Visit, the LIC 809 Facility Evaluation Report, and the LIC 809D from the previous visit dated 10/22/19 posted by the main entrance. Acknowledgement of Receipt of Licensing Reports LIC 9224 was also observed in each of the child's file.

The facility is within compliance of Title 22 Division 12 of the California Code of Regulations. Inspection report review 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: 10/29/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2019
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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