304313659-11-16-2021-06-CC-NKTN-C8TUBD-20211116142611

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304313659
Report Date: 11/16/2021
Date Signed: 11/16/2021 02:26:25 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:	CALKINS, LAURA & MICHAEL		FACILITY NUMBER:	304313659
ADMINISTRATOR:	CALKINS, LAURA & MICHAEL		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(949) 331-5765
CITY:	IRVINE	STATE: CA	ZIP CODE:	92618
CAPACITY:	14	CENSUS: 9	DATE:	11/16/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Laura Calkins, Licensee		TIME COMPLETED:	02:30 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	On 11/16/2021, Licensing Program Analyst (LPA) Nguyen Tran conducted an unannounced inspection to follow-up with a self-reported incident happened on 11/09/2021 regarding Personal Rights. LPA toured the facility with licensees Michael and Laura Calkins. LPA observed licensees and caring for 9 children. Licensee were operating within the licensed capacity as specified on license. 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 3 adults and one minor living in the home. During today's inspection, LPA interviewed Licensee and reviewed record of child #1 (C1). The unusual incident is a self-reported incident, in which Licensee forgot that C1 was allergic to dairy and gave milk to the child, causing child to have allergic reactions. Incidental Medical Service (IMS) documentation for C1 was reviewed. Based on record review and interview, on 11/09/2021, Licensee Laura Calkins, was providing milk to the children. Licensee forgot that C1 has dairy allergy and gave milk to the child. Child started to throw up after drinking the milk and Licensee came to check to find out she had accidentally gave regular milk to child instead of soy milk. Licensee immediately contacted the C1's mother, who did not want the Licensee to call 911, Licensee reported that child was throwing up and still breathing, so she did not have to administer the Epi-Pen. Parents arrived with in 8 minutes and picked child up from day care. Child returned to the day care the next day. It was determined that Licensee was aware of child’s dairy allergy but still provided the child milk. The type A violation is being cited in accordance with California Code of Regulations, Title 22, Division 12, Section 102423 Personal Rights (a) Each child receiving services from a family childcare home shall (2) To receive safe, healthful, and comfortable accommodations, furnishings, and equipment, on the attached LIC 809D (Continue next page)

SUPERVISOR'S NAME: Thuy Ho	TELEPHONE: (714) 703-2841
LICENSING EVALUATOR NAME: Nguyen K Tran	TELEPHONE: (714) 703-2818
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021

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: CALKINS, LAURA & MICHAEL	FACILITY NUMBER: 304313659
	VISIT DATE: 11/16/2021

NARRATIVE

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(Page 2 of Report)

An exit interview was completed. The report was reviewed and discussed. Appeal Rights and deficiencies were discussed. The facility representative was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Licensing office within 15 business days.

If the facility receives a Type A violation, 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. In addition, the licensee shall immediately post upon receipt the Proof of Correction for 30 consecutive days and provide a copy to current and enrolling parents. The licensee is to keep Acknowledgement Receipt (LIC 9224) signed by parents in each child’s file.

THE FACILITY REPRESENTATIVE WAS INFORMED THAT THE '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)

SUPERVISOR'S NAME: Thuy Ho	TELEPHONE: (714) 703-2841
LICENSING EVALUATOR NAME: Nguyen K Tran	TELEPHONE: (714) 703-2818
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021

LIC809 (FAS) - (06/04)

Page: 2 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: CALKINS, LAURA & MICHAEL	FACILITY NUMBER: 304313659
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/16/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/16/2021 Section Cited	1 2 3 4 5 6 7	102423 Personal Rights (a) Each child receiving services from a family childcare home shall (2) To receive safe, healthful, and comfortable accommodations, furnishings, and equipment. This requirement is not met by:
	8 9 10 11 12 13 14	Based on record reviews and interview, the licensee failed to provide a safe accommodation to the child. On 11/09/21, licensee provided milk to C1 who was allergic to dairy and licensee aware of child’s allergy, causing allergic reactions. This is an immediate threat to the children's health and safety.	8 9 10 11 12 13 14	Licensee agrees to submit picture proof of allergies list posted and an acknowledgment statement of Tittle 22, Regulation 102423 Personal Right Section (a)(2) no longer than 11/19/2021.
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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 Ho	TELEPHONE: (714) 703-2841
LICENSING EVALUATOR NAME: Nguyen K Tran	TELEPHONE: (714) 703-2818
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021

LIC809 (FAS) - (06/04)

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