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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371179
Report Date: 05/08/2023
Date Signed: 05/09/2023 09:25:28 AM


Document Has Been Signed on 05/09/2023 09:25 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868



FACILITY NAME:CALVARY CHAPEL OF YORBA LINDAFACILITY NUMBER:
304371179
ADMINISTRATOR:MYERS, BRENDAFACILITY TYPE:
850
ADDRESS:18821 YORBA LINDA BLVD.TELEPHONE:
(714) 777-7131
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY:115CENSUS: 80DATE:
05/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:33 PM
MET WITH:Director Brenda MyersTIME COMPLETED:
05:15 PM
NARRATIVE
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On 5/8/23 at 1:30pm, Licensing Program Analyst (LPA) Anna Chan conducted an onsite inspection for the purpose of an unannounced Annual Visit. LPA met with Director Brenda Myers and toured the facility inside and outside and the floor and yard plan were verified. Census was taken in individual classrooms. Children were napping when LPA arrived at the facility. The total census observed is 80 children and 9 teachers which includes 13 preschool and 2 staff on Rm#101, 5 Toddlers and 1 staff on Rm#102 or the Toddler Option Room, 13 preschool and 2 staff on Rm#103, 22 preschool and 1 staff on Rm#104, 12 preschool and 1 staff on Rm#109, 7 preschool and 1 staff on Rm#110, 8 children (K-4 age 5-5.9years old) and 1 staff on Rm#123. During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staffing ratios. Facility hours are 6:30am – 6:00pm, Monday through Friday. 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.
During the inspection of the indoor activity space, items which could pose a danger to children (detergents, cleaning compounds, and medications) were observed to be stored out of the reach of children. Poisons/Hazardous Items are not kept on the premises. Parents provide food and milk for their child or otherwise facility offers prepared lunch from third party and then prepared in the facility. Food prep areas were clean and sanitary. Food is properly stored. Menus were posted where they could be reviewed by parents. Floors, equipment, and furniture were clean and were observed to be in good repair and free of sharp edges. Age-appropriate materials such as books, puzzles, blocks and other similar items are provided for children in care. There is drinking water available to children indoors by sippy cups with the child’s name on it. Water pitcher is also available for drinking. The children's bathrooms are clean and sanitary. Children nap on cots/mats and bedding is stored individually and children take it home for washing every Friday. The facility has not conducted an emergency drill within the past six months.

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SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Anna Francesca ChanTELEPHONE: (818) 216-9775
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2023
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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Document Has Been Signed on 05/09/2023 09:25 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 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: 05/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101429(a)(2)(B)
Responsibility for Providing Care and Supervision for Infants
(B) Staff shall physically check on sleeping infant(s) every 15 minutes and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2023
Plan of Correction
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Facility stated they will start logging infant safe sleep every 15 minutes daily
Facility stated they will provide a copy of 15-minute safe sleep log to LPA by due date of 5/9/23 through email or text message
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Anna Francesca ChanTELEPHONE: (818) 216-9775
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/09/2023 09:25 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 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: 05/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101174(d)
Disaster and Mass Casualty Plan
(d) Disaster drills shall be conducted at least every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/08/2023
Plan of Correction
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Facility stated they will perform emergency drill by due date of 6/9/23
Facility stated they will provide a copy of Emergency Drill to LPA through email or text message by due date of 6/9/23
Type B
Section Cited
CCR
101221(b)(10)
Child's Records
(b) Each record shall contain information including, but not limited to, the following: (10) Record of current medications, including the name of the prescribing physician, and instructions, if any, regarding control and custody of medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on ,observation, interview and record review, the licensee did not comply with the section cited above which poses/ a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/08/2023
Plan of Correction
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Facility stated they will obatin current children medication by due date of 6/8/23
Facility stated they will provide LPA a copy of current medication through email or text message by due date of 6/8/23
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 LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Anna Francesca ChanTELEPHONE: (818) 216-9775
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2023
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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: CALVARY CHAPEL OF YORBA LINDA
FACILITY NUMBER: 304371179
VISIT DATE: 05/08/2023
NARRATIVE
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Last Emergency Drill was done October 21, 2022, which is more than 6 months as required and is found to be out of compliance. The facility has a working carbon monoxide detector and fire extinguisher. Facility met all posting requirement. The California Child Passenger Safety Law was posted by the entrance of the facility

5 Staff files were reviewed for staff present during the facility inspection on this date. Health screening and immunization as required were reviewed. Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles for staff were reviewed and within compliance. Beginning March 31, 2018, H&S Code 1596.8662 requires all directors and employees to complete mandated reporter training, and to renew the training every two years. At least one staff member present possesses current EMSA approved Pediatric CPR/First Aid certifications, which expires 09/29/23

6 Children's records were reviewed, and there was a separate, complete and current record for each child. Based on LPA record Review and Interview, facility did not comply in keeping record of current medications. An Epinephrine was expired on Nov 2022 for Child#1. In the areas reviewed the children’s files were found to out of compliance. Sign in/out procedure was reviewed for compliance. The person who signs the child in and out uses their full legal signature and records the time of the day.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. 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

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SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Anna Francesca ChanTELEPHONE: (818) 216-9775
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023
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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: CALVARY CHAPEL OF YORBA LINDA
FACILITY NUMBER: 304371179
VISIT DATE: 05/08/2023
NARRATIVE
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The outdoor activity space was inspected for compliance. The playground was enclosed by a fence at least four feet in height. The surface of the outdoor activity space was well maintained and free of hazards. There is grass and wood chips material at the climbing structure and slides which appeared to be enough to absorbs falls. Drinking water in the outdoor activity space is provided by water pitcher and sippy cups with the child’s name on it. The outdoor equipment and toys were in good repair and free of sharp edges. There are no bodies of water present at the facility. The facility grounds were safe, sanitary and in good repair.

Transfer Request (LIC9182). The Director was informed that Licensing Quarterly Updates are available at www.ccld.ca.gov director be added to an email list to receive a Quarterly Update by contacting the Child Care Advocate at childcareadvocatesprogram@dss.ca.gov or at www.ccld.ca.gov

Information on the additional nutrition training, immunization requirements for children, and Health Schools Act (http://www.cdpr.ca.gov/docs/pestmgt/schoolipm.htm) were provided. The Director was informed, and website given, about the California Child Care Disaster Plan has been posted to the UCSF California Childcare Health Program website: cchp.ucsf.edu/content/disaster-preparedness Also provided was information about the E-Learning Modules available at https://ccld.childcarevideos.org A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the facility representative.

A copy of the 2016 “A Child Care Providers Guild to Safe Sleep” was provided to the Director
English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf
AAP: https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx
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

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SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Anna Francesca ChanTELEPHONE: (818) 216-9775
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023
LIC809 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: CALVARY CHAPEL OF YORBA LINDA
FACILITY NUMBER: 304371179
VISIT DATE: 05/08/2023
NARRATIVE
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 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
· 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

Based on LPAs observations, record reviews and interview the following violation(s) were observed are being cited in accordance with California Code of Regulations, Title 22, Division 12, Chapter 3, Two Type B; Section 101174(d) Disaster and Mass Casualty Plan and 101221(b)(10) Child's Records, and One Type A Section 101429(a)(2)(B) Responsibility for Providing Care and Supervision for Infants are being cited on the attached LIC 809D.

If the facility receives a Type A violation, the licensee shall post and provide copies of the report to parents/guardians of the children in care at the facility by the next business day, and shall provide to the parents/guardians of children newly enrolled at the facility during the next 12 months. In addition, the licensee shall immediately post upon receipt the Proof of Correction for 30 consecutive days and provide a copy to current and enrolling parents. The licensee is to keep Acknowledgement Receipt (LIC 9224) signed by parents in each child’s file. Failure to post Type A reports for 30 days will result in a Civil Penalty of $100.00

An Inspection and exit interview was completed with Director Breda Myers. The report was reviewed and discussed. Appeal Rights and deficiencies were discussed. The facility representative was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days.



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.

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End of Report.

SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Anna Francesca ChanTELEPHONE: (818) 216-9775
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023
LIC809 (FAS) - (06/04)
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