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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371138
Report Date: 01/09/2023
Date Signed: 01/09/2023 12:44:53 PM

Document Has Been Signed on 01/09/2023 12:44 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:TAMURA CDC PRESCHOOLFACILITY NUMBER:
304371138
ADMINISTRATOR:MONA GREENFACILITY TYPE:
850
ADDRESS:17340 SANTA SUZANNE STTELEPHONE:
(714) 962-4099
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 48TOTAL ENROLLED CHILDREN: 48CENSUS: 36DATE:
01/09/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:16 AM
MET WITH:Cayce Korhonen, Head TeacherTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Valencia conducted an on site inspection for the purpose of a Case Management Incident inspection, in response to an Unusual Incident Report submitted to the Licensing office on 12/13/22. Census was taken in individual classrooms. The overall census observed was 36 preschool children with 6 preschool staff. This is a Title 5 program.

An Unusual Incident Report UIR LIC624 form was submitted to the Licensing office detailing that an authorized representative of a child #1 and adult #1 (see Confidential Names List LIC811) stated to Lead Teacher that their child, child #1 stated to them at home that a staff may have violated their personal rights, after adult#1 discovered a medical ailment on child #1 at home. During today's inspection, LPA Valencia conducted a physical plant inspection of the facility, observed the classroom and teacher to child interactions, a police report from FVPD related to the reported incident was gathered, and interviewed three staff as well as child #1 was interviewed. LPA will be gathering medical documentation related to the incident, as well. It was determined from the information available to LPA during the inspection, that the facility staff did not violate Title 22 Regulations related to personal rights of this incident. A printout of Title 22 Regulations Personal Rights was reviewed and provided for the facility representative.

In the areas that were evaluated, no deficiencies were observed of the California Code of Regulations, Title 22, Division 12 at the time of the visit. An exit interview was completed with facility representative and the report was reviewed and discussed. The facility representative was informed that the “Notice of Site Visit” must be posted for 30 consecutive days. The “Notice of Site Visit” must be posted on or adjacent to the door. Failure to post will result in Civil Penalties of $100.00.
SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Dean Valencia
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2023
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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