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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371149
Report Date: 01/29/2020
Date Signed: 01/30/2020 08:21:55 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:GRACE CHRISTIAN PRESCHOOLFACILITY NUMBER:
304371149
ADMINISTRATOR:PORTENEUVE, SHELBYFACILITY TYPE:
850
ADDRESS:4545 MYRA AVENUETELEPHONE:
(714) 761-5200
CITY:CYPRESSSTATE: CAZIP CODE:
90630
CAPACITY:60CENSUS: 30DATE:
01/29/2020
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Shelby Porteneuve, Director TIME COMPLETED:
03:15 PM
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Licensing Program Analyst ( LPA ) Yesenia Villa conducted an unannounced proof of correction visit on this day. Present during the inspection was lead teacher Karina Morales. LPA Villa walked the three classrooms to obtain census, there were 30 children present with 4 staff present. The facility was observed to be within ratio.A review of the Facility Personnel Report Summary on this date indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

Director Shelby Porteneuve arrived about thirty minutes after LPA Villa's arrival at the facility and continued the visit with LPA Villa. During the visit on 01/10/2020 the facility was cited for three type B deficiencies. During today's visit LPA Villa walked the playground and noticed the play yard closed off with caution tape. Director states the foam material to patch the ground ran out and therefore has not been completed. Director provided LPA Villa with a copy of the order form indicating the additional foam is scheduled to arrive between 01/29/20-02/03/20.

LPA Villa will provide an extension of the playground patching until 02/07/2020. Director states she will submit pictures of the play yard on or before this date. LPA Villa received copies of Immunization's for some of the staff. Director states her immunization have been ordered and is waiting on there arrival from her Physicians office.
An extension has been granted until 02/07/2020. Proof of Immunization's for all other staff have been submitted to the department. A proof of correction letter will be mailed once all immunization's have been received.

On this day LPA Villa provided a proof of correction letter for the deficiency related to medication training. A copy of the IMS plan was submitted to the department by the Proof of Correction date of 01/17/2020, along with a training log issued to staff on 01/17/2020 related to medication handling.An exit interview was conducted with Director Shelby Porteneuve. A notice of site visit was provided and Appeal Rights were issued and explained
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Yesenia VillaTELEPHONE: (714) 293-9465
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2020
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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