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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334811530
Report Date: 10/27/2021
Date Signed: 11/05/2021 09:56:31 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:SOUTH HILLS COMMUNITY CHURCHFACILITY NUMBER:
334811530
ADMINISTRATOR:TINA BALLARDFACILITY TYPE:
850
ADDRESS:2585 S. MAIN STREETTELEPHONE:
(951) 734-4455
CITY:CORONASTATE: CAZIP CODE:
92882
CAPACITY:120CENSUS: 48DATE:
10/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:42 AM
MET WITH:Tina BallardTIME COMPLETED:
02:03 PM
NARRATIVE
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Licensing Program Analyst (LPA), Elyse Jones conducted an annual inspection. A tour of the inside and outside of the facility was granted and the following was observed and/or noted:
A review of staff and children's records were conducted as part of this evaluation.
· The licensee/director is asked to update the following documents, if applicable, and submit to licensing within 30 days:
1. LIC 500 Personnel Report
2. LIC 610 Emergency & Disaster Plan
3. Parent Handbook/ Program Curriculum/Admission policies and procedures/ fee schedule (only if changes have been made)
4. LIC 309 Administrative Organization (only if changes have been made)
5. LIC 308 Designation of Administrative Responsibility (only if changes have been made)
· The following items have been posted and are updated where necessary:
- License
- Emergency Disaster Plan (LIC610) and Earthquake Preparedness Checklist (LIC9148)
- Parent’s Rights Poster (PUB393)
- Personal Rights (LIC613A)
- Child Car Seat Law
- Menu
· The facility is operating with the limits as stated on the license.
· Ratios are being met during this inspection
· Classrooms are adequately equipped with age and size appropriate furniture and equipment and free of hazards.
· There are no weapons present at the facility as stated by Tina Ballard
SUPERVISOR'S NAME: Aaron RossTELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse JonesTELEPHONE: (951) 897-2468
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 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: SOUTH HILLS COMMUNITY CHURCH
FACILITY NUMBER: 334811530
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101170(e)(2)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 101170(f) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the interview and record review the Licensee did not meet the above section which poses an immediate Health, Safety & Personal Rights risk to the children in care. During record review LPA discovered S1 was not associated to the facility. S1 does have a Criminal Record Clearance, however, the Department did not received the required documents to transfer the clearance. Director stated the clearance was emailed but does not have access to the email during the inspection.
POC Due Date: 10/27/2021
Plan of Correction
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Associated during inspection

Civial Penalty assesed $100/per day for 5 days.
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: Aaron RossTELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse JonesTELEPHONE: (951) 897-2468
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)
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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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: SOUTH HILLS COMMUNITY CHURCH
FACILITY NUMBER: 334811530
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.7995(a)(1)
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the interview and record review the Licensee did not meet the above section which poses an potential Health, Safety & Personal Rights risk to the children in care. During record review LPA was unable to review immunizations including MMR for S1. Director stated S1 does not have complete immunizations for S1 available for review during inspection.
POC Due Date: 11/03/2021
Plan of Correction
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Director agrees to some completed immunzations for S1 to the Department on or by 11/3/2021.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Cited in error
POC Due Date: 10/27/2021
Plan of Correction
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Cited in error
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: Aaron RossTELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse JonesTELEPHONE: (951) 897-2468
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: 8 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: SOUTH HILLS COMMUNITY CHURCH
FACILITY NUMBER: 334811530
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(g)(1)
Personnel Requirements
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the interview and record review the Licensee did not meet the above section which poses an potential Health, Safety & Personal Rights risk to the children in care. During record review LPA was unable to review an LIC 503 for S1. Director stated S1 does not have a TB screening or LIC 503 available for review during inspection.
POC Due Date: 11/03/2021
Plan of Correction
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Director agrees to submit an LIC 503 with a TB screening on or by 11/3/2021.
Type B
Section Cited
CCR
101221(b)(5)
Child's Records
(b) Each record shall contain information including, but not limited to, the following: (5) Name, address and telephone number of the child's authorized representative and of relatives or others who can assume responsibility for the child if the authorized representative cannot be reached when necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the interview and record review the Licensee did not meet the above section which poses an potential Health, Safety & Personal Rights risk to the children in care. During record review LPA was unable to review an LIC 700 for C7. Director stated C7 does not have an LIC 700 available for review during inspection.
POC Due Date: 11/03/2021
Plan of Correction
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Director agrees to submit an LIC 700 for C7 to the Department on or by 11/3/2021.
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: Aaron RossTELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse JonesTELEPHONE: (951) 897-2468
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: 7 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: SOUTH HILLS COMMUNITY CHURCH
FACILITY NUMBER: 334811530
VISIT DATE: 10/27/2021
NARRATIVE
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· There are no accessible bodies of water present. All wading pools or similar product must be emptied immediately after use and stored in an upright position.
· Present for supply drinking water in the indoor activity space. Water supplied by personal bottles filled with water from a water dispenser
· Medications are stored where inaccessible to children,
· Hazards are stored where inaccessible to children which include: Disinfectants, cleaning solutions and other items that are dangerous
· Poisons and toxins are locked
· All floors shall be clean and safe
· Bathrooms were observed to be safe, sanitary and in operating condition
· Playgrounds are enclosed by appropriate fences and free of hazards
· Outdoor activity areas are supplied with age and size appropriate equipment NOT in good condition. See LIC 9102
· Food preparation area is clean, free of litter, rubbish and free of rodents and other vermin
· Food is stored appropriately and protected from contamination
· All storage containers for solid waste, including moveable bins shall have tight-fitting covers that are kept on, and in good repair
· Menus shall be posted at least one week in advance in a place visible by the child’s authorized representative, dated and kept on file for 30 days, and made available upon request.
· Uncontaminated drinking water shall be readily available both indoors and outdoors. Outdoor was is supplied by personal bottles filled in classroom water dispensers.
· The areas around or under high climbing equipment, swings, slides, and similar equipment shall be cushioned with material that absorbs a fall. Cushioned by artificial grass.
· Sign in/Sign out record was reviewed and meets regulation requirements
· A Staff member is present with current Pediatric CPR/First Aid which expires on 8-29-2022
· Opening and closing staff member’s CPR/First Aid expires on Opener 2-1-2023, Closer 2-1-2023
· Director completed Health and Safety Training- On file
· A review of children’s records was conducted, and records were NOT complete during this inspection.
· Disaster drills to be conducted every six months – last drill conducted on 10-21-2021
SUPERVISOR'S NAME: Aaron RossTELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse JonesTELEPHONE: (951) 897-2468
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: SOUTH HILLS COMMUNITY CHURCH
FACILITY NUMBER: 334811530
VISIT DATE: 10/27/2021
NARRATIVE
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· The Licensee was informed of their reporting requirements and is provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO09@dss.ca.gov
· A review of staff records on 10-27-2021 indicates that all facility staff or other individuals who require caregiver background checks have NOT received criminal record and child abuse index clearances or exemptions.
· The Licensee can submit transfer forms to associate new individuals or to disassociate someone from your facility at: Associations_Disassociations862@dss.ca.gov
· A review of staff records indicates that all staff present meet minimum qualifications for the position for which they were hired.

- LPA discussed the safe sleep regulations with Director, Tina Ballard and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed Director, Tina Ballard of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

- This facility provides Incidental Medical Services – IMS. 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.htm

- Director, Tina Ballard 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.

- Go to the licensing webpage www.ccld.ca.gov, and click on the “Receive Important Updates” located on the right side of the page, immediately above the Quick Links. One can add their email address and choose which program(s) they wish to receive Provider Information Notices (PIN) for.

SUPERVISOR'S NAME: Aaron RossTELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse JonesTELEPHONE: (951) 897-2468
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: 5 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: SOUTH HILLS COMMUNITY CHURCH
FACILITY NUMBER: 334811530
VISIT DATE: 10/27/2021
NARRATIVE
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- To access on-line Licensing forms & Regulations for a Child Care Center please visit: www.ccld.ca.gov.

- The Duty Officer is available to answer questions Monday – Friday; 8:00am to 5:00pm at:


1-844-LET-US-NO (1-844-538-8766) and/or 951-782-4200

If a Civil Penalty has been assessed during this inspection. Payment is due when billed and the check(s) or money orders shall be made payable to the “California Department of Social Services”. YOU WILL RECEIVE AN INVOICE IN THE MAIL. DO NOT SEND MONEY UNTIL YOU RECEIVE YOUR INVOICE. DO NOT SEND CASH.

See LIC809-D for cited deficiencies.

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.

Exit interview conducted and report was reviewed with the Director, Tina Ballard.

A notice of site visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Aaron RossTELEPHONE: (951) 320-2023
LICENSING EVALUATOR NAME: Elyse JonesTELEPHONE: (951) 897-2468
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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