304371179-7-19-2019-06-CC-JMHN-BE8SWL-20190719141430

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304371179
Report Date: 07/19/2019
Date Signed: 07/19/2019 02:14:38 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:	CALVARY CHAPEL OF YORBA LINDA		FACILITY NUMBER:	304371179
ADMINISTRATOR:	MYERS, BRENDA		FACILITY TYPE:	850
ADDRESS:	18821 YORBA LINDA BLVD.		TELEPHONE:	(714) 777-7131
CITY:	YORBA LINDA	STATE: CA	ZIP CODE:	92886
CAPACITY:	115	CENSUS: 38	DATE:	07/19/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Brenda Myers		TIME COMPLETED:	11:10 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	Licensing Program Analyst (LPA), Han and Licensing Program Manager (LPM), Hanson conducted an unannounced annual/random inspection of the facility on today's date. LPAs toured the facility with the director, Brenda Myers inside and outside. Census was taken in individual classrooms. The overall census observed was 6 preschool staff and 38 preschool children. A review of staff criminal clearance records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Operating hours are 6:30 am- 6:00 pm, Mon-Fri. The facility has a preschool license with a toddler option in room #102. Census was taken. LPA observed 4 toddlers with 1 staff member. The items which could pose a danger to children items like detergents, cleaning compounds, and medications were stored out of the reach of children. Poisons/Hazardous Items are not kept on the premises. Lunch is provided by parents. AM & PM snacks are provided by facility. Food prep areas appear clean and sanitary. Food is properly stored. On site kitchen is free from hazards. The toys, floors, desks and other equipment appeared clean. There is drinking water available to children both indoors and outdoors. The children's bathrooms are clean and sanitary. Children nap on cots/mats, and bedding is taken home weekly to be washed by parents. The facility has conducted an emergency drill within the past six months. The facility has a working smoke detector, carbon monoxide detector, and fire extinguisher. The playground was completely fenced. The preschool playground equipment appeared in safe condition. The toddler playground plastic play equipment with slide was wiggling when LPA shakes it. The director ordered work to facility maintain person to fix and requested staff to not use it until it doesn’t wiggle. There is sufficient cushioning underneath climbing structures and/or play equipment to absorb falls. Sign in/out procedure was reviewed for compliance. During today’s visit, LPA observed two parents did write sign in time and full signature. At least one staff member present possesses current CPR/First Aid certifications, which expires 9/2019. Children's and staff files were reviewed for compliance. Children's and staff files were in substantial compliance.

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jung Mi Han	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2019

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: CALVARY CHAPEL OF YORBA LINDA	FACILITY NUMBER: 304371179
	VISIT DATE: 07/19/2019

NARRATIVE

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The temperature of the room should be comfortable enough for an adult to wear a t-shirt and not be too hot or too cold

Provided was information about the E-Learning Modules available at https://ccld.childcarevideos.org

The facility representative was informed that the CRIMINAL RECORD STATEMENT (LIC 508) has been updated, and the facility must now use the new form with revised date 7/15. The facility representative was also informed that the LIC 508 must be submitted with all Criminal Background Clearance Transfer Request (LIC9182). The facility representative was informed that Licensing Updates are available at www.ccld.ca.gov

Documents/Information to be updated and returned to the Licensing Office;
- Personnel Report (LIC 500)
- Emergency Disaster Plan (LIC 610)
- Designation of Administrative Responsibility (LIC 308)
- Administrative Organization (LIC 309)

Exit interview was conducted. Report reviewed and discussed. Notice of Site Visit was posted during the visit. Appeal Rights and deficiencies were discussed. The director was provided a copy of their appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Licensing office within 15 business days. Licensee was informed of how/where to access regulations and forms from CCLD website: www.ccld.ca.gov

The director 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. The “Notice of Site Visit” must be posted on or adjacent to the door.

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jung Mi Han	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2019

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: CALVARY CHAPEL OF YORBA LINDA	FACILITY NUMBER: 304371179
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/19/2019

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101229.1(a)(1)

Children Records - Sign In and Sign Out

(a) In addition to the sign-in procedure requirement of Section 101226.1(b), the licensee shall develop, maintain and implement a written procedure to sign the child in/out of the child care center that shall, at a minimum, include the following: (1) The person who signs the child in/out shall use his/her full legal signature and shall record the time of day.
	Deficient Practice Statement
1 2 3 4	Based on observation, director failed to ensure to make sure all parents write sign in and out time and full signatures. This poses a potential Safety risk to the children in care.
	POC Due Date: 08/02/2019
	Plan of Correction
1 2 3 4	The director will submit plan statement to prevent missing sign in and out time and signatures by due date by email. JUNGMI.HAN@DSS.CA.GOV

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Jung Mi Han	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2019

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: CALVARY CHAPEL OF YORBA LINDA	FACILITY NUMBER: 304371179
	VISIT DATE: 07/19/2019

NARRATIVE

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The facility does provide Incident Medical Services.
This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. 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.htm
514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

Based on LPAs record reviews, and interviews the following violations were observed is being cited in accordance with California Code of Regulations, Title 22, Division 12, Section 101229.1(a)(1). Please refer to attached 809D for documentation of deficiencies.

Proof of immunization against pertussis and measles for all employees/volunteers were reviewed for compliance with SB 792. Facility was advised on how to receive notifications for quarterly updates and provided with Child Care Advocate contact information: childcareadvocatesprogram@dss.ca.gov.
A copy of the 2016 “A Child Care Providers Guild to Safe Sleep” was provided to the facility representative.
English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf
Spanish: https//www.cdph.ca.gov/programs/SIDS/Documents/ChildCareProvSleepSPAN2011.pdf
AAP: https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx
NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative
Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials
Always place infants on their backs for sleeping
Use only a tight-fitting sheet on the crib or play yard mattress
Do not hang any items from the crib or above the crib
Keep all items, including blankets, out of the crib or play yard
Pacifiers may be used as long as they do not have items attached to them
Infants should not be swaddled or have any items covering them while sleeping

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jung Mi Han	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2019

LIC809 (FAS) - (06/04)

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