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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313472
Report Date: 05/10/2023
Date Signed: 05/10/2023 03:43:40 PM


Document Has Been Signed on 05/10/2023 03:43 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:MOUSSAVI, MANDANFACILITY NUMBER:
304313472
ADMINISTRATOR:MOUSSAVI, MANDANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
9494314893
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92692
CAPACITY:14CENSUS: 7DATE:
05/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Mandan Moussavi TIME COMPLETED:
04:30 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 licensee Mandan Moussavi
Census upon entry:
Infants:3
Children Over Two: 3
Adults Working Directly with Children: 1
Other Adults: 1
The licensee was operating within the licensed capacity as specified on the license. The Facility Day care hours are 7:30 am - 5 pm, Monday through Friday.

During today’s inspection, LPA was greeted by the licensee's Assistant #1. LPA introduced herself and informed Assistant the reason for the visit. Assistant #1 stepped in the home and went to go get licensee. Children were heard by LPA while waiting at the door. Shortly after the licensee came down stairs and met with the LPA. LPA provided the LIC 126 to the licensee and began the inspection. When LPA was confirming the areas of care and requested to see posting requirements at 12:43 pm the licensee stated the posting requirements were in a closed room. The room had two children awake in play yards yards. Other children were observed sleeping and resting in the living room.

Posted Requirements were reviewed at 12:43 pm. Upon arrival, 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. Upon inspection the posting requirements were not posted in a prominent and publicly accessible area. The licensee did not meet the requirements for posting requirements. LIC 9148 was not posted.

Facility Tour began at 12:50 pm. There is a fireplace in the living room screened by a glass cover and inaccessible to children in care.
SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Araceli BootorabiTELEPHONE: (714) 703-2800
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023
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: MOUSSAVI, MANDAN
FACILITY NUMBER: 304313472
VISIT DATE: 05/10/2023
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Detergents, cleaning compounds, and other items which could pose a danger if readily available to children were stored inaccessible to children by means of locked cabinets and knifes stored away high in the kitchen area. Licensee stated there are no firearms and/or other dangerous weapons in the facility and none were observed during today's inspections. The living room area was observed to be accessible to children and stairs were observed to have a baby gate. Licensee was given consultation on the importance of having proper baby safe gates on the stairs.

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 mats and or play pens. Bedding is stored individually and is taken home weekly to be washed by parents and some is washed by licensee. All soiled blankets and clothing are wrapped up and given to parents. Bedding is disinfected by licensee stated by the Licensee.

A consultation was given about toys and a crib observed in the play room.

The licensee stated the children's primary care and play areas consist of the living room, children activity room and backyard. The home has age-appropriate toys for the ages served.

Medications was observed to be stored in reach of the reach of children in the living room. The LPA asked licensee to put away what seemed to be medication. Licensee removed it shortly after.

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 not maintained and free of dangerous hazards to children. A large piece of furniture was observed and made of glass. The piece of furniture was not sanitary and had cigarette buds. There was one slide in the backyard for children to use and no cushion material was observed. The outdoor play house was observed to have spider webs and not in sanitary conditions. Licensee stated the children use the backyard when the weather permits. A consultation was provided to licensee on the importance on maintaining the areas the children use in care, supervision while outdoors and hazardous things observed outside.

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

DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
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: MOUSSAVI, MANDAN
FACILITY NUMBER: 304313472
VISIT DATE: 05/10/2023
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Records Reviewed at 1:21 pm.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 December 21,2022 at 10:50 am - 11 am. The licensee met the requirements during the inspection and LPA reminded the licensee of the importance of keeping documents up to date to comply consistently.

Children’s Records Reviewe:dThe LPA requested completed children’s records of children enrolled. Children's records were reviewed, and there was a separate, complete, and current record for 6 out of 7 children. 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 did not meet the requirements and a consultation was provided to support the licensee to meet compliance.

Individual Sleep Plans and Sleep Logs were reviewed at 1:53 pm in children's files. LPA observed 3 infants from 0-24 months after records were reviewed. 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 LIC 9227 Individual Infant Sleeping Plan for 0 out of 1 child 0 months - 12 months.

A facility License File Review was conducted at 1:55 pm. The LPA asked Licensee if there are any updates to be made for LIC 279, LIC 610, or LIC 999. Licensee stated there were not. A consultation was provided to update the LIC 279 and the licensee stated she did not use an email address. A consultation was provided and LPA reminded the licensee of the importance of staying up to date with regulations and changes within CCLD. LPA provided LIC311D to licensee for reference.

Personnel Records were requested by LPA at 1:58 pm.The LPA requested completed personnel records (2 of 2 adults) 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. There was no seperate file for each adult working directly with the children. Licensee provided CPR & First Aid certificates.

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

DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
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: MOUSSAVI, MANDAN
FACILITY NUMBER: 304313472
VISIT DATE: 05/10/2023
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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 on site at all times when children are present at the facility and shall be present with the children when children are off site from the facility for facility activities.CPR expiration for licensee 10/2/23 & First Aid expiration for licensee 2/12/2023

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.

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/ No completed or available for review. A consultation was provided.

This facility provides Incidental Medical Services – IMS. LPA reviewed the storage of medication and equipment/supplies and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417.

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: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
LIC809 (FAS) - (06/04)
Page: 4 of 17
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: MOUSSAVI, MANDAN
FACILITY NUMBER: 304313472
VISIT DATE: 05/10/2023
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The LPA requested to review LIC 9227 Individual Infant Sleeping Plan and Individual Infant Sleep Logs. The LPA and Licensee toured the infant napping areas and observed to be free of articles that can pose a danger to children. No LIC 9227 was observed for children 0-12 months or sleep logs for chilren 0-24 months. A copy of LIC 9227 was given to licensee.

The licensee admits to checking infants every 15 minutes and described what to look for checking for infants. License is not in compliance with Safe Sleep Regulation. The LPA provided consultation to support the license meet the requirements.

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)
- 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: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
LIC809 (FAS) - (06/04)
Page: 5 of 17
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: MOUSSAVI, MANDAN
FACILITY NUMBER: 304313472
VISIT DATE: 05/10/2023
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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.

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/

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/

Technical Assistance and Advocacy Bureau

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.

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

DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
LIC809 (FAS) - (06/04)
Page: 6 of 17
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: MOUSSAVI, MANDAN
FACILITY NUMBER: 304313472
VISIT DATE: 05/10/2023
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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

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, immunizations, 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: CCR 102425(j)(1), 102425(j)(2), 102425(j)(2)(A), 102425(j)(2)(B), 102425(j)(2)(C), 102425(j)(4), 102425(j)(5), CCR 102417(g)(4), CCR 102425(j)(2)(D), HSC 1597.622(a)(1)

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

DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
LIC809 (FAS) - (06/04)
Page: 7 of 17
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: MOUSSAVI, MANDAN
FACILITY NUMBER: 304313472
VISIT DATE: 05/10/2023
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To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at:
www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process

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

DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
LIC809 (FAS) - (06/04)
Page: 8 of 17
Document Has Been Signed on 05/10/2023 03:43 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: MOUSSAVI, MANDAN
FACILITY NUMBER: 304313472

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2023

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

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview with the licensee, and record review the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care. A consultation was provided and copies of sample logs were provided.
POC Due Date: 05/10/2023
Plan of Correction
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The licensee will begin 15 min checks for all children under 24 months.
Type A
Section Cited
CCR
102425(j)(5)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: If the infant is sleeping in a separate room from where the provider is stationed, the door to the room the infant is sleeping in shall remain open at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview with the licensee and LPA doing a record review, the licensee did not comply with the section cited above by means of having the doors closed where children were resting which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2023
Plan of Correction
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The Licensee will maintain the door open moving forward or leave assistant in the room to supervise the children in that room.
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: 05/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023
LIC809 (FAS) - (06/04)
Page: 9 of 17


Document Has Been Signed on 05/10/2023 03:43 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: MOUSSAVI, MANDAN
FACILITY NUMBER: 304313472

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(4)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the LPA observed cigarette buds and medication accessible to children in care the licensee did not comply with the section cited above which poses/posed 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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Licensee stated she was going to clean it up. Moving forwrd the licensee stated she will be storing medication away from areas children are in care
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: 05/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023
LIC809 (FAS) - (06/04)
Page: 10 of 17