304371187-7-24-2019-06-CC-JMHN-BEDVDZ-20190724162131

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304371187
Report Date: 07/24/2019
Date Signed: 07/24/2019 04:21:49 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:	KOHITSUJI PRESCHOOL		FACILITY NUMBER:	304371187
ADMINISTRATOR:	SUZUKI, TAKAKO		FACILITY TYPE:	850
ADDRESS:	15 ORANGETREE		TELEPHONE:	(714) 843-0004
CITY:	IRVINE	STATE: CA	ZIP CODE:	92618
CAPACITY:	30	CENSUS: 23	DATE:	07/24/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	08:10 AM
MET WITH:	Takako Suzuki - director		TIME COMPLETED:	02:00 PM

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 conducted an unannounced annual/random inspection of the facility on today's date. When LPA Han arrived the facility at 8:10AM, there were one staff#1, one preschool child#2, and one child#1 who is under 2 years old age in room#102. The facility has a preschool license with a toddler option. LPA requests staff#1 to contact director that LPA is at the facility for annual inspection and LPA needs to review staff/children files. Staff#1 stated the director will be at the facility by 9AM. At 8:30AM, a staff#2 arrived at the facility. The facility has separate toddler option room across from room#102. At 9:10AM, LPA Han toured the facility with the director, Takako Suzuki inside and outside. At 10:00AM, LPA observed 4 children in toddler option room with staff#1 and staff#3. 19 children in room#104 with 3 staff were singing song together. 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 8:00 am- 6:00 pm, Mon-Fri. The items which could pose a danger to children including detergents, cleaning compounds, and medications were stored out of the reach of children. Poisons/Hazardous Items are not kept on the premises. Children brings lunch. The facility provides snacks. 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. Preschool children nap on cots/mats, and bedding is taken home weekly to be washed by parents. The facility has conducted an emergency drill on 1/16/2019. The facility required to do emergency drill at least every six months. The director couldn’t find a working smoke detector at the facility. Carbon monoxide detector and fire extinguisher are in a working condition. The playground was completely fenced. The playground equipment appeared in safe condition. There is sufficient cushioning underneath climbing structures and play equipment to absorb falls.

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jung Mi Han	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2019

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: KOHITSUJI PRESCHOOL	FACILITY NUMBER: 304371187
	VISIT DATE: 07/24/2019

NARRATIVE

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Sign in/out procedure was reviewed for compliance. LPA observed three missing signatures and sign in and out time on 7/22/19 and June 2019. During today's visit staffing ratios were being met. At least one staff member present possesses current CPR/First Aid certifications, which expires 9/27/2020. Children's and staff files were reviewed for compliance. Child#2 is under 2 years old and there is no toddler option agreement which signed by parents. Child#3 was in toddler room with child#1 and child#2. Child#3 did not have toddler option agreement in file. LPA observed staff#1 was alone with 4 children between 8 AM and 8:45AM with child#1, child#3, child#7, and child#8 in room #102. Toddler (Child#1) was commingling with preschool children.
LPA interviewed staff#1 regarding her qualification as teacher since staff file has proof of 6 early childhood education (ECE) units. Staff#1 stated she completed 12 ECE units. Staff#1 showed a assistance teacher certificate provided by Irvine Valley College by cell phone. LPA request staff#1 to submit certificate and transcripts to director. LPA couldn’t verify staff#1’s qualification at the facility. All five staff did not complete Mandated Reporter Training. Director could’t provide immunization records for Staff#1, #2, #4, and #5.

The facility does not provide Incident Medical Services.
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

Based on LPAs observations, record reviews, and interviews the following violations were observed are being cited in accordance with California Code of Regulations, Title 22, Division 12, Section 101216.4(a)(2), 101216.4(a)(1), 101216.1(b)(1), 101174(d), 101229.1(a)(1) and Health and Safety 1596.8662(b)(1), 1596.7995(a)(1). Please refer to attached 809D for documentation of deficiencies.

Proof of immunization against pertussis and measles for all employees were not 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.

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jung Mi Han	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2019

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: KOHITSUJI PRESCHOOL	FACILITY NUMBER: 304371187
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/24/2019

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.7995(a)(1)

Staff Records

(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, director failed to keep staff's immunization records in each staff file. This poses a potential Safety risk to the children in care.
	POC Due Date: 07/31/2019
	Plan of Correction
1 2 3 4	Director will submit staff#1, #2, #4, and #5's immunization records including influenza, pertussis, and measles by email by due date. JUNGMI.HAN@DSS.CA.GOV

Type B

Section Cited

CCR

101174(d)

Care and Supervision

(d) Disaster drills shall be conducted at least every six months.
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, director failed to conduct fire and disaster drill at least every six months. Last drill was 1/16/2019. This poses a potential Safety risk to the children in care.
	POC Due Date: 07/31/2019
	Plan of Correction
1 2 3 4	The director will conduct fire and disaster drill this week and submit updated log by email.

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: 07/24/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2019

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: KOHITSUJI PRESCHOOL	FACILITY NUMBER: 304371187
	VISIT DATE: 07/24/2019

NARRATIVE

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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.

Failure to post Type A reports for 30 days will result in a Civil Penalty of $100.00
If the facility receives a Type A violations, 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. In addition, the licensee shall immediately post upon receipt the Proof of Correction for 30 consecutive days.

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jung Mi Han	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2019

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: KOHITSUJI PRESCHOOL	FACILITY NUMBER: 304371187
	VISIT DATE: 07/24/2019

NARRATIVE

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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
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)

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jung Mi Han	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2019

LIC809 (FAS) - (06/04)

Page: 5 of 9

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: KOHITSUJI PRESCHOOL	FACILITY NUMBER: 304371187
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/24/2019

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101216.1(b)(1)

Staff Records

(b) Prior to employment, a teacher shall meet the requirements of (b)(1) or (b)(2) below: (1) A teacher shall have completed, with passing grades, at least six postsecondary semester or equivalent quarter units of the education requirement specified in (c)(1) below; or shall have obtained a Child Development Assistant Permit issued by the California Commission on Teacher Credentialing.
	Deficient Practice Statement
1 2 3 4	Based on observation, record review, and interview, staff#1 was all by herself between 8 am and 9am with 4 children including child#1 who is under two years old. Staff#1 stated she completed 12 ECE units, but did not submit to director. LPA couldn't understand staff#1 did take infant class or not due to language issue. This poses a potential Safety risk to the children in care.
	POC Due Date: 07/31/2019
	Plan of Correction
1 2 3 4	Director will submit Staff#1's transcripts to LPA Han by email.

Type B

Section Cited

HSC

1596.8662.(b)(1)

Staff Records

1596.8662.(b)(1)… mandated reporter…proof of completion ...January 1, 2018, is a licensed child care provider..shall complete the mandated reporter training provided...renewal mandated reporter training every two years...This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, director failed to ensure to have mandated reporter training certificates for all staff. This poses a potential Safety risk to the children in care.
	POC Due Date: 07/31/2019
	Plan of Correction
1 2 3 4	Director will submit five staff's mandated reporter training certificates by due date by email.

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: 07/24/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2019

LIC809 (FAS) - (06/04)

Page: 6 of 9

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: KOHITSUJI PRESCHOOL	FACILITY NUMBER: 304371187
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/24/2019

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

101216.4(a)(2)

Toddler Component - Preschool Program with Toddler Component

Licensees serving preschool-age children may create a special program component for children who are between 18 months and 36 months of age. The provisions of Sections 101151 through 101239.2 shall apply for children over 24 months in addition to those specified in Health and Safety Code section 1596.955. The provisions of Sections 101351 through 101439.1 shall apply for children between the ages of 18 and 24 months participating in a preschool toddler component in addition to those specified in Health and Safety Code section 1596.955. (2) The toddler program shall be conducted in areas physically separate from those used by older or younger children. Space planning and usage for the toddler component shall be governed by the provisions of Section 101438.3. Plans to alternate use of outdoor play space must be approved by the Department.
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, director failed to ensure to keep physically seperate programs for Preschool and Toddler option. LPA observed child#1 was commingling with three preschool children in room#102 between 8am and 9am. Room#102 is not toddler option room. This poses an immediate Health and Safety risk to the children in care.
	POC Due Date: 07/25/2019
	Plan of Correction
1 2 3 4	Director will submit weekly staff schedule (LIC 500) to proof that covers all business hours for toddler program and preschool program.

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: 07/24/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2019

LIC809 (FAS) - (06/04)

Page: 7 of 9

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: KOHITSUJI PRESCHOOL	FACILITY NUMBER: 304371187
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/24/2019

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101229.1(a)(1)

Children Records

101229.1(a)(1)Sign In and Sign Out (a)...the licensee shall develop, maintain, and implement ...procedure...child in/out of the child care center...(1)The person who signs the child in/out shall use his/her full legal signature...record the time of day. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, director failed to ensure to have full legal signature and time on sign in and out sheet. LPA observed three missing time and signautres in July and June 2019 sheet. This poses a potential Safety risk to the children in care.
	POC Due Date: 07/31/2019
	Plan of Correction
1 2 3 4	Director will submit sign in and out plan statement to ensure to have all parent's full legal signature and time at all times by email by due date.

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: 07/24/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2019

LIC809 (FAS) - (06/04)

Page: 8 of 9

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: KOHITSUJI PRESCHOOL	FACILITY NUMBER: 304371187
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/24/2019

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101216.4(a)(1)

Toddler Component - Preschool Program with Toddler Component

Licensees serving preschool-age children may create a special program component for children who are between 18 months and 36 months of age. The provisions of Sections 101151 through 101239.2 shall apply for children over 24 months in addition to those specified in Health and Safety Code section 1596.955. The provisions of Sections 101351 through 101439.1 shall apply for children between the ages of 18 and 24 months participating in a preschool toddler component in addition to those specified in Health and Safety Code section 1596.955. (1) A child who is between 18 months and 36 months of age may participate in the toddler program with written permission from the child's authorized representative. No child in the toddler program shall be placed in the preschool program before the age of 30 months without written permission from the child's authorized representative.
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, director failed to ensure to maintain toddler option agreement in each child's file. This poses a potential Safety risk to the children in care.
	POC Due Date: 07/31/2019
	Plan of Correction
1 2 3 4	Director will submit toddler option agreements child#1 and child#9 who are under two years old by due date by email.

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: 07/24/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2019

LIC809 (FAS) - (06/04)

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