304313614-12-23-2020-06-CC-LBAS-BWL3KM-20201223171922

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304313614
Report Date: 12/23/2020
Date Signed: 12/23/2020 05:19:42 PM

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:	SIMPSON, MICHELLE		FACILITY NUMBER:	304313614
ADMINISTRATOR:	SIMPSON, MICHELLE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(562) 650-8174
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92805
CAPACITY:	14	CENSUS: 0	DATE:	12/23/2020
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	03:45 PM
MET WITH:	Licensee Michelle Simpson		TIME COMPLETED:	04:45 PM

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Tele-Inspection

An unannounced case management report was initiated on today’s date by Licensing Program Analyst LPA Barajas, during an inspection on 05/06/2020 via facetime, and a record review of the staff personnel roster inspection and interviews. LPA discovered that two staff were not associated to the day care facility.

During today’s inspection there were No children present. Based on the interviews conducted with a several staff and site Director, it has been determined that Nalleli Pina, started working at day care facility a year ago from 05/26/2020 as an assistant. Staff Nalleli Pina disclosed she worked on and off and recently she returned in February 2020 to help out Licensee as Licensee would be out on vacation in Panama. Staff Nalleli Pina disclosed last day worked was between February and March 2020, doesn't recall exact date. A Second Staff named Elizabeth Rios worked at facility for two days beginning of March 2020 on Wednesday and Thursday, Staff does not recall exact dates. LPA Barajas reviewed several Facility Personnel Report Summaries from 2019 through 03/17/2020 and Staff Nalleli Pina nor Elizabeth Rios are associated to the facility or are fingerprint cleared. Licensee Michelle Simpson failed to associate Nalleli Pina and Elizabeth Rios to facility License.

California Code of Regulations, Title 22, Division 12, Chapter 1, Criminal Record Clearance, Section 102370(d)(1) is being cited on the attached LIC 809D. A civil penalty of $500 has been assessed for Nalleli Pina and $200 for Elizabeth Rios totaling $700 for both staff.

Criminal Record Clearance 102370(d)(1) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility: (1)Obtain a California clearance or a criminal record exemption as required by the Department or

This report cites a Type A violation and shall be provided to parents/guardians of children currently in enrolled and to parents/guardians of children newly enrolled at the facility during the next 12 months.

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SUPERVISOR'S NAME: Patricia Magana	TELEPHONE: (714) 743-5149
LICENSING EVALUATOR NAME: Leonor Barajas	TELEPHONE: (714) 292-8628
LICENSING EVALUATOR SIGNATURE:	DATE: 12/23/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2020

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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: SIMPSON, MICHELLE	FACILITY NUMBER: 304313614
	VISIT DATE: 12/23/2020

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Parents/guardians must sign Form (LIC 9224) to be kept in each child's file.

Exit interview was conducted with Licensee Michelle Simpson via Tele-Inspection. Report was read to Licensee. A copy of the report along with Appeal Rights will be emailed to Licensee with a Read Receipt to acknowledge report was received. If Read Receipt is not functional, Licensee will respond to email stating “I have read and received the report, I acknowledge receipt.” LIC 9099 will also be mailed if those options are not available.

End of Report.

SUPERVISOR'S NAME: Patricia Magana	TELEPHONE: (714) 743-5149
LICENSING EVALUATOR NAME: Leonor Barajas	TELEPHONE: (714) 292-8628
LICENSING EVALUATOR SIGNATURE:	DATE: 12/23/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2020

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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: SIMPSON, MICHELLE	FACILITY NUMBER: 304313614
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/23/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/23/2020 Section Cited	1 2 3 4 5 6 7	Criminal Record Clearance 102370(d)(1) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility: (1)Obtain a California clearance or a criminal record exemption as required by the Department. This requirement is not met as evidenced by:
	8 9 10 11 12 13 14	Based on records reviewed and staff interviews,Facility Personnel Report Summaries from 2019 through 03/17/2020 and Staff Nalleli Pina nor Elizabeth Rios are associated to the facility or are fingerprint cleared.	8 9 10 11 12 13 14	Nalleli Pina and Elizabeth Rios to facility License. This poses an immediate risk to the health and safety of children in care.
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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 Magana	TELEPHONE: (714) 743-5149
LICENSING EVALUATOR NAME: Leonor Barajas	TELEPHONE: (714) 292-8628
LICENSING EVALUATOR SIGNATURE:	DATE: 12/23/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2020

LIC809 (FAS) - (06/04)

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