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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304370115
Report Date: 10/27/2023
Date Signed: 10/27/2023 06:33:25 PM


Document Has Been Signed on 10/27/2023 06:33 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:CATALYST KIDS-HICKS CANYONFACILITY NUMBER:
304370115
ADMINISTRATOR:RAIBON, KRISTENFACILITY TYPE:
840
ADDRESS:3817 VIEW PARKTELEPHONE:
(714) 544-3492
CITY:IRVINESTATE: CAZIP CODE:
92602
CAPACITY:140CENSUS: 3DATE:
10/27/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Center Manager, Ana SanchezTIME COMPLETED:
06:45 PM
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Licensing Program Analyst (LPA) Dianna Valdez Santana conducted an on-site inspection for the purpose of a Case Management Incident Inspection on 10/27/2023 LPA was met by Center Manger, Ana Sanchez that was subbing for the site Center Manger, who provided a tour of the facility. Census was taken in individual classrooms, there were 3 school-age children present upon arrival and 5 staff. Today's Case Management inspection is being conducted in response to a self-reported incident, reported to the OC CCL office on 10/10/23, detailing a child #1, had wandered out of the classroom. It was reported that the facility staff may have lacked supervision allowing the child to exit the classroom.

During the inspection, LPA interviewed two staff and child #1 (C1) involved in the incident. LPA also inspected the possible path C1 may have taken to exit classroom. LPA reviewed the Incident Report with facility representative as well as the response of the facility. On 10/09/2023, that C1 walked about 40 ft from the classroom and into the outside area where the tree sitting area is. C1 was first seen outside alone by the tree by another classmate’s relative, Adult #1 (A1). A1 walked into Room #2 and then walked out to room #1 to sign Child #2 (C2) out. C2 was signed out at 3:52pm. A1 walked in room #1 signed C2 out and then notified Staff #1 (S1) at around 3:54pm about C1 being outside. S1 immediately stood at the ramp outside the room and told C1 to come back to the class, C1 was upset and refused. S1 then called Staff 3 (S3) to come assist but S3 was breaking another staff. S1 then went to Staff #2 (S2) for assistance. S2 was able to talk to C1 and get C1 to come inside to Room #1. C1 came in about at 4:05pm. It was determined that C1 was alone without supervision for about 4-5 minutes. S1 disclosed that the door to Room #2 was usually open and that C1 had a tendency to wander the room but never thought C1 would exit the classroom. S1 stated S1 was doing a science activity with the children for “Club Time” and C1 got upset and that is when C1 walked out without S1 realizing. S1 stated it was challenging keeping an eye on C1 while C1 was outside and watching the rest of the class. From the information LPA gathered during this inspection and staff interviews, LPA determined that the facility staff failed to provide adequate supervision and C1 was able to exit the classroom without staff knowing this is Title 22 violation. Page 1 of 2
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Dianna ValdezSantanaTELEPHONE: 714-292-8628
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2023
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: CATALYST KIDS-HICKS CANYON
FACILITY NUMBER: 304370115
VISIT DATE: 10/27/2023
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Therefore, in the areas that were inspected, one Type A deficiency was observed of the California Code of Regulations, Title 22, Division 12 Section 101229(a)(1) Responsibility for Providing Care and Supervision. See attached LIC809D.

LPA Valdez Santana informed facility representative, that this report dated 10/27/2023 documents one Type A citation which shall be posted for 30 consecutive days as there is immediate risk to the health, safety, or personal rights of children in care.

LPA Valdez Santana also informed the facility representative to provide a copy of this licensing report dated 10/27/2023, that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Exit interview was conducted. The Notice of Site Visit was posted for no less than 30 consecutive days. Appeal Rights was explained The report must be posted with Notice of Site Visit . A copy of appeal rights (LIC 9058 1/16) was provided and their signatures on this form acknowledges receipt of these rights. First level appeal is to Regional Manager, address is above on the report.



Page 2 of 2. End of Report
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Dianna ValdezSantanaTELEPHONE: 714-292-8628
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/27/2023 06:33 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: CATALYST KIDS-HICKS CANYON
FACILITY NUMBER: 304370115

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/30/2023
Section Cited
CCR
101229(a)(1)

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101229(a)(1)Responsibility for Providing Care and Supervision: (a) The licensee shall provide care and supervision as necessary to meet the children's needs.
(1) No child(ren) shall be left without the supervision of a teacher at any time... Supervision shall include visual observation.
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The Facility installed a child safety gate in Room #2's door. Facility will consider installing a second child safety gate in room #1. Center Manager will email LPA their POC at dianna.valdezsantana@dss.ca.gov by POC due date.
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This requirement was not met as evidenced by: Staff 1 disclosed that Staff 1 was not aware that Child #1 had exited the classroom until Adult #1 told Staff 1. Child #1 was estimated to be left unattended for approximately 4-5 minutes and had walked about 40 ft from the classroom to the tree aitting area alone.
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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: Dianna ValdezSantanaTELEPHONE: 714-292-8628
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2023
LIC809 (FAS) - (06/04)
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