304371193-5-31-2019-06-CC-DVAA-BCPPDB-20190531111315

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304371193
Report Date: 05/31/2019
Date Signed: 05/31/2019 03:14:36 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:	NI HAO PRESCHOOL - COSTA MESA		FACILITY NUMBER:	304371193
ADMINISTRATOR:	YOLANDA ALIAGA		FACILITY TYPE:	850
ADDRESS:	827 W. STEVENS AVE		TELEPHONE:	(855) 644-2688
CITY:	SANTA ANA	STATE: CA	ZIP CODE:	92707
CAPACITY:	36	CENSUS: 8	DATE:	05/31/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Qian Gao, Head Teacher		TIME COMPLETED:	11:40 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	An inspection was conducted at the facility by LPA Dean Valencia. The facility file was reviewed prior to this inspection being conducted. A review of staff records indicates all facility staff or individuals who require caregiver background checks have received a criminal record clearances or exemptions and a child abuse index clearance. Operating hours are 7:30am to 6pm, Mon-Fri. The facility was toured inside and outside and the floor and yard plan were verified. During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staffing ratios. There were 2 staff and 8 children present during the inspection.The facility appeared clean and orderly. The items which could pose a danger to children (detergents, cleaning compounds, and medications) were stored out of the reach of children. Poisons/Hazardous Items are not stored on site and none were observed. Children nap on cots, and bedding is stored separately, and laundered at home on a weekly basis. Food is prepared on site; snacks are provided, and lunches are brought from home. Food prep areas appear clean and sanitary, food is properly stored. The facility has a monthly menu posted and is up to date. There is drinking water available to children both indoors and outdoors. The children's bathrooms are clean and sanitary. The facility has not conducted an emergency drill within the past six months, nor is documenting drills. The facility has a working smoke detector, carbon monoxide detector, and fire extinguisher. The playground is completely fenced and fencing is in good repair. The playground equipment appeared in safe condition, and the play area is free from hazards. There is sufficient cushioning underneath climbing structures and/or play equipment to absorb falls. Sign in/out procedure was reviewed for compliance. Neither staff present had proof of current pediatric CPR/First Aid certification. Children's and staff files were reviewed for compliance, and were found to be missing some documentation. 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. (continued on LIC809C)

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Dean Valencia	TELEPHONE: 714-703-2817
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2019

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 7

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: NI HAO PRESCHOOL - COSTA MESA	FACILITY NUMBER: 304371193
	VISIT DATE: 05/31/2019

NARRATIVE

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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
Proof of immunization's against pertussis, influenza (or written declination), and measles for all employees/volunteers are not on file and not being maintained. All licensing reports are public information and must be made available upon request. This report was reviewed and discussed with the the care provider. Facility was advised on how to receive notifications for quarterly updates and provided with Child Care Advocate contact information: childcareadvocatesprogram@dss.ca.gov
Beginning March 31, 2018, Health and Safety Code 1596.8662 requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years. This training was discussed with the care provider.
A pamphlet of Effects of Lead Exposure was provided for care provider and discussed.

Exit interview was conducted, and report, deficiencies, and advisory notes was reviewed and discussed. Notice of Site Visit was posted during the visit. The facility representative 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 per day. The licensee was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. First level appeal is to Regional manager, address is above on the report. The facility representative was informed of how/where to access regulations and forms from CCLD website: www.ccld.ca.gov. and accessibility and access to the website was discussed with the care provider. This report is to be on file and accessible for public review at the facility for at least 3 years.

The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see attached LIC 809D.

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Dean Valencia	TELEPHONE: 714-703-2817
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2019

LIC809 (FAS) - (06/04)

Page: 2 of 7

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: NI HAO PRESCHOOL - COSTA MESA	FACILITY NUMBER: 304371193
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/31/2019

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101217(a)(12)

Staff Records - Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) Tuberculosis test documents as specified in Section 101216(g).
	Deficient Practice Statement
1 2 3 4	Based on a review of the staff records, it was determined that two of the staff records did not have a Tuberculosis Test available to review. This is a potential threat to the children's health and safety.
	POC Due Date: 06/14/2019
	Plan of Correction
1 2 3 4	The care provider stated she will have the facility submit to LPA copies of the two staff's Tuberculosis Tests, by 6/14/19. Contact information for LPA was left with the care provider.

Type B

Section Cited

CCR

101217(a)(13)

Staff Records - Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) A signed statement regarding their criminal record history as required by Section 101170(d).
	Deficient Practice Statement
1 2 3 4	Based on a review of the staff's records it was determined that two of the staff records did not have a Crimal Record Statement LIC508 available to review. This is a potential threat to the children's health and safety.
	POC Due Date: 06/14/2019
	Plan of Correction
1 2 3 4	The care provider stated she will have the facility submit to LPA copies of the two staff's criminal record statemens, by 6/14/19. Contact information for LPA was left with the care provider.

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: Dean Valencia	TELEPHONE: 714-703-2817
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2019

LIC809 (FAS) - (06/04)

Page: 3 of 7

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: NI HAO PRESCHOOL - COSTA MESA	FACILITY NUMBER: 304371193
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/31/2019

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101174(a)

Physical Plant - Disaster and Mass Casualty Plan

(a) Each licensee shall have a disaster and mass casualty plan of action. The plan shall be in writing and shall be readily available.
	Deficient Practice Statement
1 2 3 4	Based on information obtained from an interview with the care provider, it was determined that the facility has not been conducting emergency drills, nor documenting record of the drill. This is a potential threat to the children's health and safety.
	POC Due Date: 06/14/2019
	Plan of Correction
1 2 3 4	The care provider stated she will have the facility submit proof to LPA that the facility has conducted an emergency drill, and will continue to conduct and document these drills at least every six months. Proof of this drill will be submitted to LPA by 6/14/19, and contact information of LPA was left with care provider.

Type B

Section Cited

HSC

1596.7995(a)(1)

Staff Records - General Provisions and Definitions

(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 a review of the staff files, it was determined that two of the staff files did not have proof of immunizations on file available to review. This is a potential threat to the children's health and safety.
	POC Due Date: 06/14/2019
	Plan of Correction
1 2 3 4	The care provider stated she will have the facility submit proof to LPA of the staff's proof of immunization records against pertussis, influenza (or written declination), and measles. Proof of these records will be submitted to LPA by 6/14/19, and contact information of LPA was left with care provider.

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: Dean Valencia	TELEPHONE: 714-703-2817
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2019

LIC809 (FAS) - (06/04)

Page: 4 of 7

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: NI HAO PRESCHOOL - COSTA MESA	FACILITY NUMBER: 304371193
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/31/2019

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101220(a)

Children Records - Child's Medical Assessments

(a) Prior to, or within 30 calendar days following the enrollment of a child, the licensee shall obtain a written medical assessment of the child. This medical assessment enables the licensee to assess whether the center can provide necessary health-related services to the child.
	Deficient Practice Statement
1 2 3 4	Based on a review of the child's files, it was determined that the children's medical assessment forms were not being filed out completely or were not being signed by a physician. This is a potential threat to the children's health and safety.
	POC Due Date: 06/14/2019
	Plan of Correction
1 2 3 4	The care provider stated that she will have the facility submit to LPA proof that the children's medical assessments are being filed out completely and correctly. Proof of this will be submitted to LPA by 6/14/19, and contact information of LPA was left with the care provider.

Type B

Section Cited

CCR

101220.1(g)

Children Records - Immunizations

(g) The licensee shall document each child's immunizations and shall maintain such documentation in the center for as long as the child is enrolled.
	Deficient Practice Statement
1 2 3 4	Based on a review of the child's files, it was determined that the facility is not maintaining record of the children's immunization records. This is a potential threat to the children's health and safety.
	POC Due Date: 06/14/2019
	Plan of Correction
1 2 3 4	The care provider stated that she will have the facility submit to LPA proof that the children's immunizations records are on fiel and being updated. Proof of this will be submitted to LPA by 6/14/19, and contact information of LPA was left with the care provider.

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: Dean Valencia	TELEPHONE: 714-703-2817
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2019

LIC809 (FAS) - (06/04)

Page: 5 of 7

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: NI HAO PRESCHOOL - COSTA MESA	FACILITY NUMBER: 304371193
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/31/2019

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101216.1(g)

Staff Records - Teacher Qualifications and Duties

(g) A photocopy of the teacher's Child Development Permit as specified in (c)(3) above, or a photocopy of the teacher's transcript(s) documenting successful completion of required course work, shall be maintained at the center.
	Deficient Practice Statement
1 2 3 4	Based on a review of the staff records, it was determined that two of the staff records did not have transcripts or qualifications available to review. This is a potential threat to the children's health and safety.
	POC Due Date: 06/14/2019
	Plan of Correction
1 2 3 4	The care provider stated she will have the facility submit to LPA copies of the two staff's qualifications/transcripts, by 6/14/19. Contact information for LPA was left with the care provider.

Type B

Section Cited

CCR

101217(a)(11)

Staff Records - Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 101216(g).
	Deficient Practice Statement
1 2 3 4	Based on a review of the staff records, it was determined that two of the staff records did not have a health screening report to review. This is a potential threat to the children's health and safety.
	POC Due Date: 06/14/2019
	Plan of Correction
1 2 3 4	The care provider stated she will have the facility submit to LPA copies of the two staff's health screeening reports, by 6/14/19. Contact information for LPA was left with the care provider.

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: Dean Valencia	TELEPHONE: 714-703-2817
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2019

LIC809 (FAS) - (06/04)

Page: 6 of 7

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: NI HAO PRESCHOOL - COSTA MESA	FACILITY NUMBER: 304371193
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/31/2019

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101216(f)

Staff Records - Personnel Requirements

(f) At least one staff member who is trained in pediatric cardiopulmonary resuscitation and pediatric first aid pursuant to Health and Safety Code Section 1596.866 shall be present when children are at the child care center or offsite for center activities.
	Deficient Practice Statement
1 2 3 4	Based on interview with both staff and a review of their records, it was determiend that neither of the two staff were able to show proof of current pediatric CPR First aid certification, nor had the certification on file. This is a potential threat to the children's health and safety.
	POC Due Date: 06/14/2019
	Plan of Correction
1 2 3 4	The care provider stated that the facility will submit proof of current pediatric CPR/Firest Aid certification of the staff, to LPA by 6/14/19. Contact information for LPA was left with care provider.

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: Dean Valencia	TELEPHONE: 714-703-2817
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2019

LIC809 (FAS) - (06/04)

Page: 7 of 7