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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371216
Report Date: 11/02/2021
Date Signed: 11/02/2021 03:31:47 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:LEPORT-IRVINE SPECTRUM -SOUTH CAMPUSFACILITY NUMBER:
304371216
ADMINISTRATOR:RATNAYAKE, AYANTHIFACILITY TYPE:
830
ADDRESS:1 TECHNOLOGY DRIVE BLDG HTELEPHONE:
(408) 973-7337
CITY:IRVINESTATE: CAZIP CODE:
92618
CAPACITY:36CENSUS: 20DATE:
11/02/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:31 PM
MET WITH:Ayanthi Ratnayake, directorTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Valencia conducted an on site inspection for the purpose of a Case Management Incident inspection, in response to an Unusual Incident Report submitted to the Licensing office on 10/25/21. An Unusual Incident Report UIR LIC624 form was submitted to the Licensing office on 10/25/21 detailing that a a child, child #1 (see Confidential Names List LIC811), ingested a food that the child was allergic to, was given Benadryl, then an epinephrine device, and 911/emergency services called and child taken to CHOC. During today's inspection, LPA conducted a physical plant inspection, interviewed director and 3 other staff, interviewed an adult #2, and gathered and reviewed documentation related to the incident. It was determined from the information available to LPA during the inspection, that the a child #1 ingested a food, and began sustaining symptoms of allergic reaction. A staff #1 and staff #2 witnessed onset of symptoms. Symptoms began to continue and increase in severity. An adult #1 was called who instructed staff #1 to administer Benadryl. Symptoms continued to worsen. A staff #3 and director entered classroom and witnessed symptoms of child, and called emergency services. It was then determined that a staff #2 should administer the child's prescribed epinephrine pen. Symptoms immediately subsided once the epinephrine was given. An adult#2 and emergency services arrived and child #1 was transported to CHOC. It was determined from interview that from onset of first symptoms to administration of epinephrine device, was approximately 18 to 20 minutes. Child #1 has since returned to care at the facility. Upon review of child's medical documentation, it was determined that the facility did not have the child's medical orders/prescription information on file to review. LPA has determined from the information gathered that facility violated Title 22 Regulations regarding Health Related Services 101226(b), 101226(c) and 101226(e)(3)(a) and also Personal Rights 101223(a)(2). A printout of Title 22 Regulations Health Related Services and Personal Rights was reviewed and provided for the director. In response to this incident director will be sending all staff information related to Incidental Medical Services (IMS) and administration of epinephrine devices. Director will be obtaining medical order/prescription information from child #1's authorized representatives. All of this information and corrections in response to the violations cited and incident, will be submitted to LPA promptly. (continued on LIC809C)
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Dean ValenciaTELEPHONE: (714) 215-6737
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
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 4
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: LEPORT-IRVINE SPECTRUM -SOUTH CAMPUS
FACILITY NUMBER: 304371216
VISIT DATE: 11/02/2021
NARRATIVE
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(page 2)

Based on information LPA gathered during today's inspection, the following violation(s) was determined to have occurred, and is being cited in accordance with Regulations Title 22 Section 101223(a)(2), 101226(b), 101226(c), and 101226(e)(3)(a) cited on the attached LIC 809D.

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. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee. 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
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Dean ValenciaTELEPHONE: (714) 215-6737
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: LEPORT-IRVINE SPECTRUM -SOUTH CAMPUS
FACILITY NUMBER: 304371216
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
11/02/2021
Section Cited

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The licensee shall make prompt arrangements for obtaining medical treatment for any child if necessary.
This was not met as evideced by:

Based on interviews and info gathered by LPA Valencia, it was determined that after a staff #1 and staff #2 became aware of a child's
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allergic reaction they did not call 911 immediately nor administetred an epinephrine pen. An adult #1 was called and advised staff to give Benadryl. Staff did not seek appropriate medical attention in a timely manner. This is an immediate threat to the child's/children's health, safety, and personl rights.
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these corrections will be submitted to LPA promptly, and on file.
Request Denied
Type A
11/02/2021
Section Cited

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The licensee shall obtain emergency medical treatment without specific instructions from the child's authorized representative if the authorized representative cannot be reached immediately, or if the nature of the child's illness or injury is such that there should be no delay in getting medical treatment for the child. This was not met as evidenced by:
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 Based on interviews and info gathered by LPA Valencia, it was determined that staff failed to obtain prompt and appropriate medical treatment for a child's serious allergic reaction. This is an immediate threat to the child's/children's health, safety, and personl rights.
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these corrections will be submitted to LPA promptly, and on file.
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 HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Dean ValenciaTELEPHONE: (714) 215-6737
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: LEPORT-IRVINE SPECTRUM -SOUTH CAMPUS
FACILITY NUMBER: 304371216
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
11/02/2021
Section Cited

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Prescription medications shall be administered in accordance with the label directions as prescribed by the child's physician. This was not met as evidenced by:

Based on interviews and information gathered by LPA Valencia, it was determined that the facility does not have medical orders or
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prescription information information from child #1's doctor. This information is to be on file and reviewable at all times a child with IMS is in care. This is an immediate threat to the child's/children's health, safety, and personl rights.
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these corrections will be submitted to LPA promptly, and on file.
Request Denied
Type A
11/02/2021
Section Cited

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To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
This was not met as evidence by:

Based on interviews and information gathered by LPA Valencia, it was determined that staff did not meet a child with allergy's needs.
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Child sustained a severe allergic reaction to food ingested, for approximately 18 to 20 minutes before being given the appropriate medical response from the facility, a prescribed epinephrine pen. This is an immediate threat to the child's/children's health, safety, and personl rights.
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these corrections will be submitted to LPA promptly, and on file.
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 HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Dean ValenciaTELEPHONE: (714) 215-6737
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4