304371230-10-28-2021-06-CC-MMAK-C8829F-20211027171152

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304371230
Report Date: 10/27/2021
Date Signed: 10/28/2021 07:53:18 AM

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:	FUTABA PRESCHOOL		FACILITY NUMBER:	304371230
ADMINISTRATOR:	CHIZUKO, NAKAMURA		FACILITY TYPE:	850
ADDRESS:	23802 AVENIDA DE LA CARLOTA		TELEPHONE:	(949) 444-9403
CITY:	LAGUNA HILLS	STATE: CA	ZIP CODE:	92653
CAPACITY:	57	CENSUS: 27	DATE:	10/27/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Director		TIME COMPLETED:	05:45 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	Page 1 of 3 Licensing Program Analyst (LPA) Mahnaz (Nancy) Malek conducted an onsite inspection for the purpose of an Annual Inspection. The Covid-19 Emergency Response questionnaire was reviewed and answered by the director. LPA and the licensee, Yuki Ishida toured the facility inside and outside, and the floor and yard plan (LIC 999) were verified. Census was taken in individual classrooms. The overall census observed was 27 children including one toddler from Toddler Option and 6 staff in classrooms # 106, 108, and 110. Room # 114 was for Toddler Option Program. Due to COVID 19 guidelines, LPA observed staff and children wearing face mask, social distancing and following CDC and Dept of Public Health Guidelines. During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staff to child ratios. Facility hours are 8am - 6pm., 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. Licensee was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated. 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. The facility does not provide snacks and lunches. The parents provide it. Floors, equipment, and furniture were clean and observed to be in good repair and free of sharp edges. There is drinking water available to children indoors by children's own water bottles. The children's bathrooms are clean and sanitary. Children nap on cots, bedding is stored individually and is taken home daily to be washed by parents. The facility has conducted an emergency drill within the past six months and keeps documentation of drills. The facility has a at least one working smoke detector, one working carbon monoxide detector and at least one functioning fire extinguisher. Facility meets all posting Continued on page 2

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Mahnaz Malek	TELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021

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: FUTABA PRESCHOOL	FACILITY NUMBER: 304371230
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/27/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101226(e)(3)(A)

Health-Related Services

(3) Prescription medications may be administered if all of the following conditions are met: (A) Prescription medications shall be administered in accordance with the label directions as prescribed by the child's physician. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation of the storage of medication at 2:30 pm, the licensee did not comply with the section cited above in one child's medication container without a label which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/05/2021
	Plan of Correction
1 2 3 4	The licensee agreed to have the child's representative get the appropriate label for the child's medication by the due date of 11/5/2021. The licensee will send the label with the instruction to LPA's email address.

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: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Mahnaz Malek	TELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021

LIC809 (FAS) - (06/04)

Page: 4 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: FUTABA PRESCHOOL	FACILITY NUMBER: 304371230
	VISIT DATE: 10/27/2021

NARRATIVE

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The outdoor activity space was inspected for compliance. The playground is enclosed by a fence at least four feet in height and is in good repair. The surface of the outdoor activity space is maintained and free of hazards. The cushioning material around outdoor play equipment and other similar equipment appeared to be enough to absorbs falls. Drinking water in the outdoor activity space is provided by children's own water bottles. The outdoor equipment and toys are in good repair and free of sharp edges. There are no bodies of water present at the facility. The inspected outdoor facility grounds are safe, sanitary and in good repair.
Staff files were reviewed for staff present during the facility inspection on this date. 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 all staff were reviewed and within compliance. Beginning March 31, 2018, H&S Code 1596.8662 requires all directors and employees to complete mandated reporting training, and to renew the training every two years. At least one staff member present possesses current EMSA approved Pediatric CPR/First Aid certifications.
Children's records were reviewed, and there was a separate, complete and current record for each child.
This facility provides Incidental Medical Services. 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.htmThe Director was informed that Licensing Quarterly Updates are available at www.ccld.ca.gov Director may request to 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
LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian
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 facility representative was informed, and website given, about the California Child Care Disaster Plan has been posted to the UCSF
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SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Mahnaz Malek	TELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021

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: FUTABA PRESCHOOL	FACILITY NUMBER: 304371230
	VISIT DATE: 10/27/2021

NARRATIVE

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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.
LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage athttps://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource.
Based on LPA's observation of the storage of medications, the following violation was observed and is being cited in accordance with California Code of Regulations, Title 22, Division 12, Chapter 3, Section 101226(e)(3)(A), being cited on the attached LIC 809D.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee, Yuki Ishida.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Mahnaz Malek	TELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021

LIC809 (FAS) - (06/04)

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