304370206-9-3-2019-06-CC-STOE-BFNQHH-20190903121111

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304370206
Report Date: 09/03/2019
Date Signed: 09/03/2019 12:11:16 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:	INTERNATIONAL CHURCH OF THE FOURSQUARE GOSPEL		FACILITY NUMBER:	304370206
ADMINISTRATOR:	JANINE, CEBALLOS		FACILITY TYPE:	830
ADDRESS:	123 WEST ASH STREET		TELEPHONE:	(714) 529-7019
CITY:	BREA	STATE: CA	ZIP CODE:	92821
CAPACITY:	9	CENSUS: 6	DATE:	09/03/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	08:28 AM
MET WITH:	Janine Ceballos, Director		TIME COMPLETED:	10:05 AM

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	An unannounced inspection was conducted by the Licensing Program Analyst (LPA) Torrence on 09/03/2019. During this inspection, LPA Torrence met with Director Janine Ceballos, who guided analyst on a tour of the Early Childhood Setting indoors and outdoors. Census was taken. There was a total of six infants present. LPA observed five infants being supervised by one staff, in the activity area, and one infant asleep, in a crib, being supervised by one staff, in the napping area. Operation hours are 7:00 a.m. to 6:00 p.m. Monday to Friday. During this visit, it was determined the facility is operating within its licensed capacity and within compliance of staffing ratio. A review of staff records indicates all facility staff or individuals who require caregiver background checks have received a criminal record clearance or exemption and a child abuse index clearance. The facility was reviewed to ensure compliance with license conditions and limitations, staffing and ratios, inaccessibility to poisons, medication, and hazardous items that can pose a danger to children. Equipment and furniture were inspected to ensure it's in good condition, free of sharp, loose or pointed parts. The bins had tight fitting covers. The napping area is separated from the activity area and has sufficient infant napping equipment. There were no baby walkers observed on the premises. The changing table was within the arm's reach of a sink. Bottles and dishes are labeled with the current date and children's names. There are no weapons, firearms or bodies of water in the facility per the Director. The playground was inspected for safety, good condition of equipment, including appropriate cushioning material around and under high climbing equipment. There was a carbon monoxide detector present during today's inspection. The facility has a fire alarm system. Staff's files were reviewed for education verification, CPR/First Aid, infant units, Staff had the required mandated reporter training on file and the required immunization's on file for Pertussis, Measles, and Influenza. A sample of children's files were reviewed for completeness of medical assessment, and verification of sign in/out including time the child was signed in/out by authorized representative as well as verification of

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Stacy Torrence	TELEPHONE: (714) 300-3599
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2019

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: INTERNATIONAL CHURCH OF THE FOURSQUARE GOSPEL	FACILITY NUMBER: 304370206
	VISIT DATE: 09/03/2019

NARRATIVE

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representative’s full legal signature. The facility has an individual feeding plan for each infant and each infant has an infant Needs and Services Plan.

The Incidental Medical Services-IMS was discussed. For IMS information see Evaluator Manual- Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. 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) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http:/www.ada.gov/childqanda.htmThe updated plan of operation has been received in our office for providing Incidental Medical Services. (IMS)

Facility was advised on how to receive notifications for quarterly updates and provided with Child Care Advocate contact information: childcareadvocatesprogram@dss.ca.gov . Licensee was informed of how/where to access regulations and forms from CCLD website: www.ccld.ca.gov

During this inspection, there were no deficiency cited in accordance with California Code of Regulations, Title 22.

Exit interview was conducted. Report reviewed and discussed. 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. Notice of Site Visit was posted during the visit. Appeal rights provided and explained. The director was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights.

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Stacy Torrence	TELEPHONE: (714) 300-3599
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2019

LIC809 (FAS) - (06/04)

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