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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313514
Report Date: 01/19/2023
Date Signed: 01/19/2023 02:46:19 PM


Document Has Been Signed on 01/19/2023 02:46 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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868



FACILITY NAME:JOHNSTON, YUKARIFACILITY NUMBER:
304313514
ADMINISTRATOR:JOHNSTON, YUKARIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 230-9002
CITY:IRVINESTATE: CAZIP CODE:
92614
CAPACITY:14CENSUS: 6DATE:
01/19/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Natsumi Iwahara. AssistantTIME COMPLETED:
03:00 PM
NARRATIVE
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LPA Torrence conducted a case management visit to ensure licensee posted the Notice of Site Visit and Licensing report documenting a type A deficiency. Upon arrival, LPA Torrence met with Assistant Natsumi Iwahara. Also present was Assistant Miyuki Tsumori. Licensee was not present at the facility. Ms. Natsumi asked LPA if she wanted her to call licensee. Ms. Natsumi called licensee and LPA was able to speak to licensee. Licensee stated she was out of state visiting family and will be back tonight. LPA Torrence tour the facility with Ms. Natsumi, there were three infants and three preschool children being supervised by two Assistants.

A review of the Facility Personnel Report Summary on this date indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

LPA Torrence was informed by parents that the licensee did not post the Notice of Site Visit or the Licensing report documenting the type A deficiency. LPA observed the Notice of Site Visit, the Licensing report, and Proof of Correction of Type A Violation posted on the parents’ board, located in directly in front of the front door. LPA was also informed by parents that they did not receive a copy of the licensing report documenting the type A deficiency. LPA reviewed eight children’s files and discovered none of the files contained the LIC 9224- Acknowledgement of Receipt of Licensing Report.

Based on LPAs records reviews and observation, the following Health and Safety 1596.8595 ( c )(1) violation was observed and is being cited in accordance and is being cited on the attached LIC 809D.
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Stacy TorrenceTELEPHONE: (714) 300-3599
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023
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 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: JOHNSTON, YUKARI
FACILITY NUMBER: 304313514
VISIT DATE: 01/19/2023
NARRATIVE
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Exit interview conducted and report was reviewed with the licensee Heidi Shikuma. Appeal Rights was discussed. The facility representative was provided a copy of their appeal rights (LIC 9058) 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.

The facility representative was informed that the “Notice of Site Visit” must be posted for 30 consecutive days. The “Notice of Site Visit” must be posted on or adjacent to the door. Failure to post will result in Civil Penalties of $100.00.

SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Stacy TorrenceTELEPHONE: (714) 300-3599
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/19/2023 02:46 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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868


FACILITY NAME: JOHNSTON, YUKARI
FACILITY NUMBER: 304313514

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/17/2023
Section Cited

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1596.8595(c)(1) H&S 1596.8595(c)(1) Posting licensing report by child care facility or home.. (c)(1) A licensed child day care facility shall provide to the parents or guardians of each child receiving services in the facility copies of any licensing report that documents any Type A citation that represents an immediate risk to the health, safety, or personal rights…..
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LPA will informed director to send in copies of the LIC 9224 for all the parents of the children in care.
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This requirement is not met as evidence by: Based on LPAs records reviews, interviews, and observation, it was discovered that licensee failed to give parents copies of the licensing report that documents any Type A…. and the LIC 9224 Acknowledgment of Receipt of Licensing Report to the parents of the children in care. This poses a potential risk to the health 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) 287-8515
LICENSING EVALUATOR NAME: Stacy TorrenceTELEPHONE: (714) 300-3599
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3