304370316-3-12-2021-06-CC-CODM-BZ2QZK-20210312113652

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304370316
Report Date: 03/12/2021
Date Signed: 03/12/2021 11:37:02 AM

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:	KELLIE'S ACADEMY FOR KIDS, CHILD DEV. CTR.		FACILITY NUMBER:	304370316
ADMINISTRATOR:	FERRIA, DANAE		FACILITY TYPE:	830
ADDRESS:	5702 CLARK DRIVE		TELEPHONE:	(714) 377-0533
CITY:	HUNTINGTON BEACH	STATE: CA	ZIP CODE:	92649
CAPACITY:	28	CENSUS: 11	DATE:	03/12/2021
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	DarraLynn VadeBoncoeur- Office Administrator		TIME COMPLETED:	12:00 PM

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An unannounced case management report was initiated on today’s date by Licensing Program Analyst (LPA’s) Odom and VanZant, during delivering complaint findings. LPA’s discovered that an individual: Destinee Sepulveda was not associated to the facility.

During today's inspection there were a total of 11 infant children; 3 infants in Infant classroom with 2 staff, and 8 toddlers in the toddler classroom with 2 staff.

A review of staff records indicates that all facility staff or other individuals who require caregiver background checks do not have criminal record and child abuse index clearances or exemptions, Staff Destinee Sepulveda was in the toddler classroom caring for 8 children.

Based on the interview conducted, Office Administrator stated, staff was hired on February 19,2021 and the association forms were faxed and mailed to licensing office. LPA Odom asked for copies of LIC9182 Criminal Background Clearance Transfer Request form created for Staff, but Office Administrator was not able to provide copies of forms or proof that forms were sent to licensing office.

Licensee will be cited for Criminal Record violation, Type A for: Destinee Sepulveda, California Code of Regulations, Title 22, Division 12, Chapter 1, Section 101170(e)(2) 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: (2) Request a transfer of a criminal record clearance as specified in Section 101170(f) Therefore is being cited on the attached LIC 809D.

A civil penalty of $500 has been assessed for: Destinee Sepulveda.

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.

Continue to page 2.

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen Odom	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2021

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: KELLIE'S ACADEMY FOR KIDS, CHILD DEV. CTR.	FACILITY NUMBER: 304370316
	VISIT DATE: 03/12/2021

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

Exit interview was conducted. Notice of Site Visit was posted during the visit. Licensee 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. Licensee was provided a copy of their appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. First level appeals should be sent to the regional manager to the address listed above

End of Report

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen Odom	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2021

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: KELLIE'S ACADEMY FOR KIDS, CHILD DEV. CTR.	FACILITY NUMBER: 304370316
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/12/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/12/2021 Section Cited	1 2 3 4 5 6 7	101170(e)(2) Criminal Record Clearance: (e)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: (2) Request a transfer of a criminal record clearance as specified in Section 101170(f) This requirement is not met as evidence by:
	8 9 10 11 12 13 14	Based on observation and interview Office administrator did not have a copy of LIC9182 Criminal Background Clearance Tranfer Request form available to show proof that was sent to licensing office. This is an immediate risk to the health and safety of the children in care.	8 9 10 11 12 13 14
	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: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen Odom	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2021

LIC809 (FAS) - (06/04)

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