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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343620812
Report Date: 06/24/2021
Date Signed: 06/24/2021 12:22:02 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:BURNS, BREANNAFACILITY NUMBER:
343620812
ADMINISTRATOR:BURNS, BREANNAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 293-2458
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:14CENSUS: 7DATE:
06/24/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Breanna BurnsTIME COMPLETED:
12:30 PM
NARRATIVE
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On Thursday, June 24th, 2021 at 10:30 AM, Licensing Program Analyst (LPA) Kelly Ferrara conducted a Case Management Inspection at the facility and met with Licensee Breanna Burns. Today's census included seven children supervised by the Licensee and two assistants.

LPA arrived at the home at approximately 10:30 AM and spoke to Licensee inside until approximately 10:45 AM. At that time, LPA and Licensee went into the backyard and LPA observed a kiddie pool filled with water on the patio that was not covered or fenced in and children playing outside. Licensee explained that the children were going to be doing water play and they had just filled up the pool. LPA was outside until approximately 11:30 AM and the children were not using the pool, however they were playing near the water and had to be redirected away.

One Type A Title 22 deficiency was cited on the subsequent page of this report. Owner and Director acknowledge, that FOR TYPE A DEFICIENCIES ONLY upon receipt, Director shall post LIC 809 D with Type A deficiencies for 30 days and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. LIC 9224 must be signed by parents/guardians and kept with the children's forms as a receipt whenever any Type A documents are provided by the licensee. LIC 9224 and Appeal Rights were provided.
SUPERVISOR'S NAME: Maria MayorgaTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Kelly FerraraTELEPHONE: (916) 425-5932
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021
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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: BURNS, BREANNA
FACILITY NUMBER: 343620812
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
06/25/2021
Section Cited

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All licensees shall ensure the inaccessibility of pools....bodies of water through a pool cover or by surrounding the pool with a fence.

This requirement was not met as evidenced by: LPA observed a kiddie pool filled with water that was not covered and accessible to children who were playing near it.

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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: Maria MayorgaTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Kelly FerraraTELEPHONE: (916) 425-5932
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2021
LIC809 (FAS) - (06/04)
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