304313430-6-20-2023-06-CC-ANUZ-CSYMNZ-20230620094620

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304313430
Report Date: 06/19/2023
Date Signed: 06/20/2023 09:47:20 AM

Document Has Been Signed on 06/20/2023 09:47 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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME:	HOLLAND, JACQUELINE		FACILITY NUMBER:	304313430
ADMINISTRATOR:	HOLLAND, JACQUELINE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(949) 689-9971
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92627
CAPACITY:	14	CENSUS: 13	DATE:	06/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Licensee, Jacqueline Holland		TIME COMPLETED:	01:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	An Annual Random inspection was conducted at the facility by Licensing Program Analyst (LPA) Aiddee Nunez. LPA met with licensee and census was taken. There were 13 preschool children, the licensee, and 3 teacher assistants in the day care area. Licensee was operating within the licensed capacity as specified on license. A review of the Facility Personnel Report Summary on this date indicates not all facility staff who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Staff #1 and Staff #2 do not have a criminal background check. Staff #1 and Staff # 2 left the facility and will return once they have a criminal background clearance. Currently there are 2 adults including the licensee and 3 minor children living in the facility. Facility Day care hours are 8am to 12pm Monday through Friday. During today’s inspection, LPA and licensee toured the inside and outside areas identified in the facility sketch as accessible to child care children. Off limits areas are made inaccessible by means of locked doors. The child care area consist of the outside play area which is the children’s classroom and is accessed through the outside gate. The children walk through the kitchen and living room to access the bathroom. Licensee stated the children's primary area is the outside play area. There are working carbon monoxide, smoke detector, and fire extinguishers in the home that meet statutory and State Fire Marshall standards. Detergents, cleaning compounds, medicines, and other items which could pose a danger if readily available to children were stored inaccessible to children. Licensee stated there are firearms in the facility. There are no fireplace or an open-faced heater in the facility. The home has age appropriate toys for the ages served. LPA verified there is a working cellular service. There were no poisons or other items observed which could pose a danger to children or if they were observed, they were locked or inaccessible. There are no bodies of water on the premises. Page 1 of 4

SUPERVISOR'S NAME: Thuy Ho	TELEPHONE: (714) 703-2800
LICENSING EVALUATOR NAME: Aiddee Nunez	TELEPHONE: 714-703-2800
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

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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Document Has Been Signed on 06/20/2023 09:47 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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: HOLLAND, JACQUELINE	FACILITY NUMBER: 304313430
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in Licensee and Staff #3 not having a current mandated reporter training certificate which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/10/2023
	Plan of Correction
1 2 3 4	Licensee and Staff # 3 will submit their renewal mandated reporter training by the POC due date and will send a copy to the LPA via email.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Ho	TELEPHONE: (714) 703-2800
LICENSING EVALUATOR NAME: Aiddee Nunez	TELEPHONE: 714-703-2800
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

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: HOLLAND, JACQUELINE	FACILITY NUMBER: 304313430
	VISIT DATE: 06/19/2023

NARRATIVE

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The licensee does have a current roster of children in care. Children’s records for children present during LPA’s inspection were reviewed for a copy of the emergency information card that contains all the information specified by regulation (LIC 700) and found to be in compliance.

The licensee and assistant’s Pediatric CPR/First Aid certification expired 11/14/2024. Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles for licensee and staff were reviewed and within compliance. Beginning March 31, 2018, H&S Code 1596.8662 requires all licensed providers and employees to complete mandated reporting training, and to renew the training every two years. The licensee and Staff # 3 do not have a current mandated reporter training certificate.

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/childqanda.htm

The licensee understands she 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 and supervise children while absent. The substitute adult must have the required criminal record, child abuse index clearances, immunizations, Pediatric CPR/First Aid, and mandated reporter training. LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian

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SUPERVISOR'S NAME: Thuy Ho	TELEPHONE: (714) 703-2800
LICENSING EVALUATOR NAME: Aiddee Nunez	TELEPHONE: 714-703-2800
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

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: HOLLAND, JACQUELINE	FACILITY NUMBER: 304313430
	VISIT DATE: 06/19/2023

NARRATIVE

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CCLD website www.ccld.ca.gov was provided to licensee 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 link
A copy of the 2016 “A Child Care Providers Guide to Safe Sleep” was provided to the licensee. The following electronic links were also provided:
English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf
AAP:https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspxNIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative
Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials
LPA reviewed with licensee the following safe sleep best practices:
· Always place infants on their backs for sleeping
· 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.

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SUPERVISOR'S NAME: Thuy Ho	TELEPHONE: (714) 703-2800
LICENSING EVALUATOR NAME: Aiddee Nunez	TELEPHONE: 714-703-2800
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

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: HOLLAND, JACQUELINE	FACILITY NUMBER: 304313430
	VISIT DATE: 06/19/2023

NARRATIVE

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A copy of the Provider Information Notice (PIN) 20-06-CCP Social and Physical Distancing Guidance and Healthy practices for childcare facilities in response to the global coronavirus (COVID-19) pandemic written in collaboration with the CA Department of Education. A copy of COVID-19 posters and Essential workers list.

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: Administration of Child Day Care Licensing 1596.8662 (b) (1) and Criminal Record Clearance 102370 (d) (1) (see LIC 809D).

Due to the Type A violations cited today, the licensee shall post, and provide copies, of the report to parents/guardians of the children in care at the facility by the next business day, and shall provide to the parents/guardians of children newly enrolled at the facility during the next 12 months. The licensee is to keep Acknowledgement Receipt (LIC 9224) signed by parents in each child’s file. In addition, the licensee shall immediately post upon receipt the Proof of Correction for 30 consecutive days.

An exit interview was conducted with licensee . Appeal Rights were explained. The Licensee was provided a copy of appeal rights (LIC 9058 01/16) 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. First level appeals should be sent to the regional manager to the address listed above. The Notice of Site Visit was posted and discussed as required by H&S Code Sec. 1596.817. Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100.00. The Notice of Site Visit must be posted on or adjacent to the door.

End of Report

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SUPERVISOR'S NAME: Thuy Ho	TELEPHONE: (714) 703-2800
LICENSING EVALUATOR NAME: Aiddee Nunez	TELEPHONE: 714-703-2800
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

LIC809 (FAS) - (06/04)

Page: 6 of 6

Document Has Been Signed on 06/20/2023 09:47 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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: HOLLAND, JACQUELINE	FACILITY NUMBER: 304313430
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

102370(d)(1)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in Avery Roldan that started working in September 2022 and Clarisa Begin-Roh that started working in January 2023 not having a criminal record clearance and helping with the family child care home during operating hours which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/19/2023
	Plan of Correction
1 2 3 4	Avery Roldan and Clarisa Begin-Roh need to obtain Criminal Record Clearance prior to being inside a family child care home during operating hours.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Ho	TELEPHONE: (714) 703-2800
LICENSING EVALUATOR NAME: Aiddee Nunez	TELEPHONE: 714-703-2800
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

LIC809 (FAS) - (06/04)

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