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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304312854
Report Date: 04/26/2023
Date Signed: 04/26/2023 12:59:12 PM


Document Has Been Signed on 04/26/2023 12:59 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:AFSHAR, HALLEHFACILITY NUMBER:
304312854
ADMINISTRATOR:AFSHAR, HALLEHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 607-9396
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:14CENSUS: 7DATE:
04/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Maryam AkhondiTIME COMPLETED:
01:15 PM
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An Annual Random inspection was conducted at the facility by Licensing Program Analyst (LPA) Mrs. Bootorabi. Upon arrival, an Entrance Checklist (LIC 126) was provided to the assistant #1

Census upon entry:
Infants:3
Children Over Two: 4
Adults Working Directly with Children: 1
Other Adults: 0
The licensee was operating within the licensed capacity as specified on the license. The Facility Day care hours are 7 am - 5:30 pm Monday - Friday

During today’s inspection, LPA observed one adult assistant #1 and 7 children in care. There was one infant in a play yard, and 6 children playing. The living room was blocked off by means of a baby gate blocking the stairs to prevent children from going to the middle level. There was 5 play yards in the living room, two bouncers, and toys for children to play with. Children bottles were observed with no labels. A facility tour began at 9:30 am.

Facility Tour began at 9:30 am. The inside and outside was toured with Assistant #1. The LPA and assistant #1 toured the facility inside and outside. The facility sketch (LIC 999) was verified. Areas stated to be off-limits by the facility sketch were blocked off by baby safe gates.

Detergents, cleaning compounds, medicines, and other items which could pose a danger if readily available to children were stored inaccessible to children by means of off limit areas being blocked off by baby gates. Licensee stated there are no firearms and/or other dangerous weapons in the facility and none were observed during today's inspections.

SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Araceli BootorabiTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2023
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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: AFSHAR, HALLEH
FACILITY NUMBER: 304312854
VISIT DATE: 04/26/2023
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Floors, equipment, and furniture were clean and were observed to be in good repair and free of sharp edges. The children's bathrooms are clean and sanitary. Children nap on the floor that is covered with soft cushioning in the living room and play yards and bedding is stored individually and is washed by License at end of the week. All soiled blankets and clothing are put inside a plastic bag and parents take it home to clean stated by the Assistant #1.

The play yards were observed to contain blankets and pillows where infants are napping. Pacifiers were observed in the play yards and children are assigned an individual play yard while in care. A consultation was provided for Safe Sleep during exit interview. 11:45 am The LPA observed play yards to not have blankets and pillows. Licensee stated the blankets and pillows are removed for infants and are only used for children 3 years and up. Only for children three and up who nap in play yards have blankets and pillows.

During the inspection of the indoor activity space, items that could pose a danger to children (detergents, cleaning compounds, and medications) were observed to be stored out of the reach of children. The LPA observed Poisons/Hazardous Items (detergents, cleaning compounds, and medications) out of reach of children in care.

Outdoor Space toured at 9:35 am. The outdoor activity space was inspected for compliance. The playground was enclosed by a fence at least four feet in height. The surface of the outdoor activity space was maintained. The LPA observed 1 AC unit and a smaller air unit in the back yard where children play. A consultation was provided about best practice for the AC units in the play area the children are in.

The outdoor space contained slides and other climbing equipment that was age appropriate. A consultation was provided for best practice on having soft matter in the bottom all around of the climbing equipment. Currently soft tiles are at the end of the slide. A consultation was provided for health, safety and supervision.

The licensee stated the children's primary care and play areas consist of the living room and a portion of the patio area outside. The home has age-appropriate toys for the ages served. Children nap and play in the living room, have outdoor play area in the patio. The backyard is fenced with netting to prevent children from going into off limit backyard area. A water fountain was observed to be full of plants in the back yard. The children have meals either on a portable table licensee brings in or on the floor stated by licensee.

SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Araceli BootorabiTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023
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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: AFSHAR, HALLEH
FACILITY NUMBER: 304312854
VISIT DATE: 04/26/2023
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Posted Requirements were reviewed at 9:40 am. The LPA verified that the following documents were posted in a prominent, publicly accessible area; License, PUB 394 Notification of Parents’ Rights, and LIC 9148 Earthquake Preparedness. The licensee met the requirements.
Records review at 9:45 am. The LPA requested to review the LIC 610A Emergency Disaster Plan, Verification of Disaster and Fire Drills, and LIC 9040 Facility Roster. The last drill was conducted on 12/2022 at 9:40 am. The LPA provided a consultation on the importance of conducting the drills, and noting the date and time appropriately.

Children’s Records Reviewed at 09:53 am.The LPA requested completed children’s records of children enrolled. Children's records were reviewed, and there was a separate and current record for each child. The LPA reviewed files to verify the following documents LIC 282 Affidavit Regarding Liability Insurance, Immunization Records, LIC 700 Identification and Emergency Medical Treatment, and LIC 995A Notification of Parents’ Rights. The licensee was not in compliance and a consultation was provided to support the licensee to meet compliance.

Individual Sleep Plans and Sleep Logs were reviewed.LPA observed (3 infants) from 0-24 months. An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and maintained at the facility in the infant’s file. LPA observed and reviewed 1 of 3 LIC 9227 Individual Infant Sleeping Plan in children’s files. Licensee did not have infant sleep logs to review during the inspection A consultation was provided.

Identify Location & Functioning was verified at 10:45 am. The licensee tested the carbon monoxide and smoke detector during today’s inspection. Both were functioning. The licensee and LPA reviewed the Fire Extinguisher and were extinguisher was marked in full.

Personnel Records were reviewed at 11:10 am. The LPA requested completed personnel records (2 of 2 adults working with the children) for review during today’s inspection. The following documents were reviewed in the files provided by the licensee; CPR First Aid Certification, LIC 9052, Immunization records, TB clearance and LIC 9108, and a Mandated Reporter Training Certificate.

SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Araceli BootorabiTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023
LIC809 (FAS) - (06/04)
Page: 3 of 16
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: AFSHAR, HALLEH
FACILITY NUMBER: 304312854
VISIT DATE: 04/26/2023
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CPR & FIRST AID: Family daycare homes shall ensure that at least one staff member who has a current course completion card in pediatric first aid and pediatric CPR issued by the American Red Cross, the American Heart Association, or by a training program that has been approved by the Emergency Medical Services Authority pursuant to this section and Section 1797.191 shall be onsite at all times when children are present at the facility and shall be present with the children when children are offsite from the facility for facility activities. Licensee and Assistant CPR & First Aid were verified and expire on 6/25/2022

Mandated Reporter Training: Health and Safety Code (HSC) section 1596.8662 requires all licensed child care providers, administrators and employees of licensed child care facilities, and applicants for family child care home licenses to complete child abuse-mandated reporter training and to renew the training every two years. Licensee and Assistant #1 date of completion was 09/03/2020.

For additional information and resources on Child Abuse Mandated Reporting, please see the CDSS Resources for Providers. For all other questions, please contact your Local Regional Office. https://mandatedreporterca.com/

The facility did not meet the requirements due to the following documents not available for review or expired: Mandated Reporter Training Expired. A consultation was provided to support licensee meet requirements

Incidental Medical Services (IMS) policy was discussed and the licensee stated she does not provide IMS currently in her FCCH. 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) Commonly Asked Questions American Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

Know the Law About The Americans with Disabilities Act and Individuals with Disabilities Education Act https://rrnetwork.org/assets/general-files/Child-Care-Law-Center-ADA_IDEA_Housing-April-2019.pdf

SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Araceli BootorabiTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023
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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: AFSHAR, HALLEH
FACILITY NUMBER: 304312854
VISIT DATE: 04/26/2023
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Safe Sleep:The LPA requested to review LIC 9227 Individual Infant Sleeping Plan and Individual Infant Sleep Logs. The licensee admits to checking infants every 15 minutes and described what to look for checking for infants but does not have logs for review or records of past logs. License did not meet the Safe Sleep Regulation. The LPA provided consultation to support the license meet the requirements.

Safe SleepConsultation began at 12:26

During today’s inspection, the licensee and LPA discussed the following:

- Stay up to date with LIC 9227 and discuss with parents any new changes


- Ensure 15 min checks are conducted & logged (The initial of the person checking should be included, logs should be available fore review)
- The importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.
- Always place infants on their backs to sleep
- Use only a tight-fitting sheet on the crib or play yard mattress
- Do not hang any items from the crib or above the crib
- Keep all items, including blankets, out of the crib or play yard
- Pacifiers may be used if they do not have items attached to them
- Infants should not be swaddled or have any items covering them while sleeping
- The temperature of the room should be comfortable enough for an adult to wear a t-shirt and not be too hot or too cold.

The following are additional resources.
https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep
The American Academy of Pediatric https://www.aap.org/en/patient-care/safe-sleep/
Safe Sleep Regulations https://cdss.ca.gov/Portals/9/Additional-Resources/Legislation-and-Regulations/Public%20Hearing%20Docs/f031803RegulationsTextOALfinal.pdf
SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Araceli BootorabiTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023
LIC809 (FAS) - (06/04)
Page: 5 of 16
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: AFSHAR, HALLEH
FACILITY NUMBER: 304312854
VISIT DATE: 04/26/2023
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Licensee had no questions in regards to SAFE SLEEP at this time.

Background Checks :A review of the Facility Personnel Report Summary on this date indicates all facility residents, staff, or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Currently, there are 2 adults including the licensee and 0 minor child living in the facility. The licensee was reminded that any individuals 18 years or older must have a background check clearance. The licensee was also reminded that any children turning 18 years must obtain a background check to maintain compliance.

Criminal Record Clearance Consultation


· All individuals subject to a criminal record review under Health and Safety Code Section 1596.871 shall before working, residing, or volunteering in a licensed facility:

· Obtain a California clearance or a criminal record exemption as required by the Department or (2) Request a transfer of a criminal record clearance as specified in Section 102370(j) or (3) Request and be approved for a transfer of a criminal record exemption, as specified in Section 102370.1(p), unless, upon request for a transfer, the Department permits the individual to be employed, reside, or be present at the facility.
· Violation of Section 102370(d) will result in a citation of a deficiency and an immediate assessment of civil penalties of one hundred dollars ($100) per violation per day for a maximum of five (5) days by the Department.
· Subsequent violations within a twelve (12) month period will result in a civil penalty of one hundred dollars ($100) per violation per day for a maximum of thirty (30) days.
· The Department may assess civil penalties for continued violations as permitted by Health and Safety Code Section 1596.99.

LPA provided Guardian Information and website info:
https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian
Video: https://ccld.childcarevideos.org/family-child-care-providers/background-check-requirements-for-caregivers/
SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Araceli BootorabiTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023
LIC809 (FAS) - (06/04)
Page: 6 of 16
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: AFSHAR, HALLEH
FACILITY NUMBER: 304312854
VISIT DATE: 04/26/2023
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Reminders: CCLD website www.ccld.ca.gov was provided to licensees to access regulations, updates, and licensing forms.

The licensee was informed of the important updates available at www.ccld.ca.gov and may request to be added to an email list to receive Community Care Licensing Important Notifications from the above website and selecting Receive Important Updates: https://www.cdss.ca.gov/inforesources/community-care-licensing/policy/provider-information-notices/child-care

Other useful resources include https://ccld.childcarevideos.org/family-child-care-providers/ (ALL)

Technical Assistance and Advocacy Bureau (Flier of TSP was provided)

The Community Care Licensing Division, Technical Assistance and Advocacy Bureau will host a webinar via phone or ZOOM to inform providers about the no-cost services offered by the Technical Support Program (TSP). Webinar Date and Time Tuesday, June 6, 2023, 6:00 p.m.

Register in advance for this webinar: Zoom Registration Link After registering, you will receive a confirmation email containing information about joining the webinar. Tip: Save the link to your Outlook calendar for easy access to the webinar.

https://us02web.zoom.us/webinar/register/WN_fJWLW7U8Q-StwMIlUxMjaA

SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Araceli BootorabiTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023
LIC809 (FAS) - (06/04)
Page: 7 of 16
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: AFSHAR, HALLEH
FACILITY NUMBER: 304312854
VISIT DATE: 04/26/2023
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The licensee understands they must be present in the facility and must ensure children in care are always supervised. Children are not to be left alone in parked vehicles. When the licensee is temporarily absent from the facility, arrangements must be made for a qualified substitute adult to care for and supervise children while absent. The substitute adult must have the required criminal record, child abuse index clearances, immunization's, Pediatric CPR/First Aid, and mandated reporter training.

The facility was not in compliance and violations of the California Code of Regulations, Title 22, Division 12 were observed, discussed, and cited at the time of the visit.



The following violations of the California Code of Regulations, Title 22; Division 12, were observed and cited today
SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Araceli BootorabiTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023
LIC809 (FAS) - (06/04)
Page: 8 of 16
Document Has Been Signed on 04/26/2023 12:59 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: AFSHAR, HALLEH
FACILITY NUMBER: 304312854

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2023
Plan of Correction
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The licensee/assistant will be completing the LIC 9227 and provide proof of correction via email to the LPA. Moving the licensee and assitant will ensure the children have completed files.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Araceli BootorabiTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2023
LIC809 (FAS) - (06/04)
Page: 9 of 16


Document Has Been Signed on 04/26/2023 12:59 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: AFSHAR, HALLEH
FACILITY NUMBER: 304312854

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviewing the licensee and record review of childrens files, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2023
Plan of Correction
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Moving forward the licensee stated she will be creating a sleep log and keeping record of each log for review. Licensee wiil be emailing lincensee proof of correction.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, 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:
Deficient Practice Statement
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Based on record review of personnel , the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. The licensee Mandated Reporter was expired and a consultation was provided..
POC Due Date: 05/12/2023
Plan of Correction
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2
3
4
The licensee will be completing the training and provide proof via email to LPA.
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: Araceli BootorabiTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2023
LIC809 (FAS) - (06/04)
Page: 10 of 16