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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304312679
Report Date: 10/30/2023
Date Signed: 10/30/2023 06:14:35 PM


Document Has Been Signed on 10/30/2023 06:14 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:VILLASENOR, LOURDESFACILITY NUMBER:
304312679
ADMINISTRATOR:VILLASENOR, LOURDESFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 587-4267
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY:14CENSUS: 0DATE:
10/30/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Licensee, Lourdes VillasenorTIME COMPLETED:
06:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Aiddee Nunez conducted an unannounced case management incident inspection in response to a self-report Unusual Incident dated 10/30/2023. LPA met with Licensee, Lourdes Villasenor. LPA observed no children at the time of the visit.

A review of staff criminal clearance 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.

On 10/30/2023 a self-reported Unusual Incident Report (UIR) was filed with the Licensing Office. The Licensee reported that Child#1 (C1) was not responsive. Licensee performed CPR and called 911.

According to the Licensee on 10/30/23 C1 arrived at the facility around 8:15am to 8:20am. C1 was brought by Parent#1 (P1) and C1 was awake when C1 was dropped off. Licensee asked P1 how C1 was doing because C1 had been sick last week. P1 told licensee that C1 did not have a cough anymore but had a lot of phlegm and that C1 had a doctor’s appointment today or tomorrow (licensee can’t remember exactly what day P1 told her). When licensee received C1 Licensee checked C1. Licensee stated C1 was smiling and looked fine. Licensee was holding and talking to C1 for about 10 to 15 minutes then put C1 on the play yard. C1 fell asleep after been put on the play yard for about 30 minutes. When C1 was asleep the Licensee was checking on C1 to see if C1 had a temperature, the licensee stated C1 was fine, and everything seemed normal. When C1 woke up, Licensee picked up C1 and feed C1 a bottle but C1 did not want to eat, the Licensee then burp C1 and held C1 for about 10 minutes. Licensee then put C1 on the play yard and C1 slept again for about 25 minutes. When C1 woke up, Licensee checked C1’s diaper and changed C1’s diaper.

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SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 703-2800
LICENSING EVALUATOR NAME: Aiddee NunezTELEPHONE: 714-703-2800
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023
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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: VILLASENOR, LOURDES
FACILITY NUMBER: 304312679
VISIT DATE: 10/30/2023
NARRATIVE
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After Licensee changed C1’s diaper the licensee started to do some movements on C1. Licensee stated Licensee started to move C1’s legs and arms up and down for about 5 times. After, the licensee put C1 on the play yard. Licensee stated that C1 was awake, fine, and normal when Licensee put C1 on the play yard. While C1 was in the play yard for about 20 minutes the licensee was passing and checking on C1 as licensee was caring for the other children. As licensee turned to check on C1, licensee saw that C1 was laying down and C1 had C1’s eyes closed. Licensee went to C1 to check on to see if C1 had a temperature, but licensee stated that C1 was not responding to licensee’s touch and C1 was not moving or responding. Licensees pick up C1 and started to performed CPR. C1 was still not responding, and Licensee’s niece called 911 at 11:05am. Licensee’s assistant then started to perform CPR on C1 and C1 was still not responding. Licensee’s niece then started to perform CPR on C1 by the guidance of the 911 operator. Lincensee stated that the ambulance arrived 7 minutes later after the 911 phone call. The paramedics perform CPR to C1 and took C1 to the hospital. Licensee stated that licensee had 4 children including C1 during the time of the incident.

Licensee stated that the police officers took C1’s file. LPA Nunez obtained a copy of the children’s roster, reviewed licensees and assistant files.

Based on LPA's record reviews it was observed that licensee and assistant CPR/First Aid training is not EMSA approved. Also, LPA asked licensee about C1’s sleeping log and Sleeping Plan LIC 9227. Licensee stated that licensee did not have a sleeping log or the LIC 9227 form for C1.

The facility was not in compliance of the California Code of Regulations, Title 22, Division 12. The following citation section 102425(j)(2) Infant Safe Sleep, 102425(c) Infant Safe Sleep, and 102416 (c) Personnel Requirements were issued today on the attached LIC 809D.



Exit interview was conducted. Notice of Site Visit was posted during the visit. Licensee, Lourdes Villasenor 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 01/16) and their signature on this form acknowledges receipt of these rights. First level appeals should be sent to the regional manager to the address listed above.
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 703-2800
LICENSING EVALUATOR NAME: Aiddee NunezTELEPHONE: 714-703-2800
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/30/2023 06:14 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: VILLASENOR, LOURDES
FACILITY NUMBER: 304312679

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/07/2023
Section Cited
CCR
102425(j)(a)

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102425(j)(a) Safe Sleep. (j) The provider shall supervise infants while they are sleeping and adhere to the following requirements (a)The provider shall check and document the following:




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Licensee stated, they will begin to document on the sleeping log when the infants are sleeping every 15 minutes. Licensee will submit the completed sleeping log to licensing department by the due date. The licensee will also provide a written statement by the POC due date.
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Based on record review, licensee stated that licensee did not have a napping log documented for C1. Licensee did not comply with the section cited which poses a potential health, safety or personal rights risk to persons in care.
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Type B
11/07/2023
Section Cited
CCR102425(c)(1)(2)

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102425(c)(1)(2) Infant Safe Sleep. (c) An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 month of age...(1)This plan shall be signed and dated by the infant’s authorized representative, (2) The Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be maintained in the infant’s file and shall be available to the Department for review.
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Per licensee, she will have parent fill out the LIC 9227 and submit copy to LPA via email, by POC due date, and keep in child's file. The licensee will aslo write a written statment and send it via email to LPA by the POC due date.
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This requirement is not met by evidence, C #1 does not have a completed LIC 9227 in file. This poses a potential threat to the 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: Thuy HoTELEPHONE: (714) 703-2800
LICENSING EVALUATOR NAME: Aiddee NunezTELEPHONE: 714-703-2800
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 10/30/2023 06:14 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: VILLASENOR, LOURDES
FACILITY NUMBER: 304312679

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/30/2023
Section Cited
CCR
102416(c)

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102416(c) Personnel Requirements. The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.
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Licensee will provide a copy of a CPR/First Aid training certificate that is EMSA approved to the LPA via email by the POC due date.
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Based on record review, the licensee did not comply with the section cited above in not having a CPR/First Aid training that is affiliated to the EMSA which poses/posed a potential health, safety or personal rights risk to persons 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: Thuy HoTELEPHONE: (714) 703-2800
LICENSING EVALUATOR NAME: Aiddee NunezTELEPHONE: 714-703-2800
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023
LIC809 (FAS) - (06/04)
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