304370640-12-16-2021-06-CC-MMAK-C9RP82-20211216100445

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304370640
Report Date: 12/16/2021
Date Signed: 12/16/2021 10:04:59 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:	CATALYST KIDS-ORCHARD HILLS		FACILITY NUMBER:	304370640
ADMINISTRATOR:	MARIANA BOSCH		FACILITY TYPE:	840
ADDRESS:	11555 CULVER DRIVE		TELEPHONE:	(714) 734-3699
CITY:	IRVINE	STATE: CA	ZIP CODE:	92604
CAPACITY:	105	CENSUS: 5	DATE:	12/16/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	07:15 AM
MET WITH:	Staff in charge		TIME COMPLETED:	09:30 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	Page 1 of 2 On 12/16/21 Licensing Program Analyst (LPA) Mahnaz (Nancy) Malek conducted a case management of the facility for an incident which was self reported by the facility representative to our office on 12/14/21. The Covid-19 Emergency Response questionnaire was answered by Justin Pukasamsombut who was supervising 4 school age children in room # 1. The 5th school age child arrived during the inspection. A review of staff records on this date indicated that all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions. According to the facility self report, it states it was observed by a witness that 4 children were left unattended in room # 1 while staff #1 was in the other room on 12/13/21. Today LPA discussed the incident with the program Director (Mariana Bosch) over the phone, interviewed one staff, and 5 present children. Staff # 1 mentioned in the incident was not present. Based on the information obtained through the witness of the incident, 3 staff, and 4 children out of 5 present children today, there are enough evidence that staff # 1 was left 4 children unattended in room # 1 while being in room # 2. However the length of the time of absence of supervision is unknown. According to interviews the duration of absence might have happened couple of minutes. Room # 1 and Room # 2 are connected. There is an slight open entrance between them. Therefore there was no visual observation of children from room to room except for the slight entrance. It was confirmed by interviews that staff # 1 was not able to see the children when the incident happened. Based on the information obtained, it was found out the absence of supervision has occurred for 4 school age children on 12/13/21 while staff # 1 was in room # 2. Continued on page 2

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Mahnaz Malek	TELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021

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: CATALYST KIDS-ORCHARD HILLS	FACILITY NUMBER: 304370640
	VISIT DATE: 12/16/2021

NARRATIVE

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Section 101229(a)(1 Responsibility for Providing Care and Supervision was cited on LIC 809D.

Upon receipt of Type A violations, the licensee shall post and provide copies of the report to parents/guardians of the children in care at the facility, and to the parents/guardians of children newly enrolled at the facility during the next 12 months. The licensee is to keep Acknowledgement Receipt (LIC 9224) signed by parents in each child’s file. The Notice of Site Visit was posted. 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.

Exit interview was conducted.

End of report

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Mahnaz Malek	TELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021

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: CATALYST KIDS-ORCHARD HILLS	FACILITY NUMBER: 304370640
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/16/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/16/2021 Section Cited	1 2 3 4 5 6 7	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, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
	8 9 10 11 12 13 14	Based on the information obtained through the witness of the incident, one staff, and 4 children out of 5 present children today, there are enough evidence that staff # 1 was left 4 children unattended in room # 1 while being in room # 2. The staff failed to meet the above Regulations. This is an immediate risk to the health and safety of children in care.	8 9 10 11 12 13 14	An immediate civil penalty of 500.00 is hereby assessed for absence of supervision for today and 100.00 per day until corrected.
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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: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Mahnaz Malek	TELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021

LIC809 (FAS) - (06/04)

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