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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360910507
Report Date: 10/22/2021
Date Signed: 10/22/2021 07:42:57 PM

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:CHILDTIME CHILDREN'S CENTERSFACILITY NUMBER:
360910507
ADMINISTRATOR:TONI GAVELLFACILITY TYPE:
850
ADDRESS:3656 RIVERSIDE DR.TELEPHONE:
(909) 591-9169
CITY:CHINO,STATE: CAZIP CODE:
91710
CAPACITY:69CENSUS: 37DATE:
10/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Director Charlene BunnellTIME COMPLETED:
07:45 PM
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On 10/22/2021, Licensing Program Analyst (LPA) Destinee Hogue conducted a required annual inspection as part of a compliance review. A tour of the inside and outside of the facility was granted and the following was observed and discussed with Director, Charlene Bunnell:

This is a combination center and the other licensed programs were not inspected on this date.

A review of a sampling of the staff records and children's records were conducted as part of this evaluation.

· The following items have been posted and are updated where necessary:
v License
v Emergency Disaster Plan (LIC610) and Earthquake Preparedness Checklist (LIC9148)
v Parent’s Rights Poster (PUB393)
v Personal Rights (LIC613A),
v Child Car Seat Law
v Menu

· ZERO TOLERANCE - There are no bodies of water present. All wading pools or similar product must be emptied immediately after use and stored in an upright position.
· ZERO TOLERANCE - No weapons stored at the facility
· Hazards are stored where inaccessible to children which include: disinfectants, cleaning solutions and other items that are dangerous to children.
· Poisons and toxins were inaccessible, but not locked during this inspection. SEE LIC809D for cited deficiencies
· Medications are stored where inaccessible to children
· Classrooms are equipped with age appropriate furniture and equipment in good condition. Furniture and equipment shall be in good condition, free of sharp, loose, or pointed parts.
SUPERVISOR'S NAME: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Destinee HogueTELEPHONE: (951) 218-5196
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021
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 9
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: CHILDTIME CHILDREN'S CENTERS
FACILITY NUMBER: 360910507
VISIT DATE: 10/22/2021
NARRATIVE
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· Outdoor activity areas are supplied with age and size appropriate equipment in good condition
· Playgrounds are enclosed by appropriate fences and free of hazards
· The surface of the outdoor activity space is free of hazards. LPA observed wood chips and sand surrounding the outdoor activity space.
· All toilets, handwashing, and bathing facilities are in safe and operating condition, at this time.
· All floors were observed to be clean and free from hazards
· Food preparation area is clean and free of vermin
· Food is stored appropriately and protected from contamination
· All storage containers for solid waste, including moveable bins have tight-fitting covers that were on and in good repair, at this time.
· Uncontaminated drinking water shall be readily available both indoors and out. Drinking water is supplied by water faucet with water jug and plastic cups in each classroom.
· The areas around or under high climbing equipment, swings, slides, and similar equipment shall be cushioned with material that absorbs a fall.
· The Licensee shall ensure the facility is free of flies, other insects and rodents.
· Outdoor activity space surfaces shall be free of hazards.
· Appropriate carbon monoxide detector is present and was tested by the Director during this inspection.
· Licensee/Director understands the Child Care Center shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children, employees and visitors.
· ZERO TOLERANCE - The Department has inspection authority as specified in Health & Safety Code sections 1596.852, 1596.853, and 1596.8535.
· The Department shall notify a Licensee to immediately terminate the employment of, or to remove/bar any person with specified convictions or for other reasons. The Licensee shall comply with the notice.
· The facility is operating within the terms of the license.
· A review of staff records on 10/22/2021 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.
· A Staff member is present with current Pediatric CPR/First Aid which expires on 04/2023 and closing staff CPR/First Aid expires on 07/2022
· Licensee understand the name of the Child Care Center Director or fully qualified teacher(s) designated to act in the Director's absence shall be reported to the Department within 10 days of a change.
· Sign in/Sign out record was reviewed and meets regulation requirements, at this time.
SUPERVISOR'S NAME: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Destinee HogueTELEPHONE: (951) 218-5196
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021
LIC809 (FAS) - (06/04)
Page: 2 of 9
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: CHILDTIME CHILDREN'S CENTERS
FACILITY NUMBER: 360910507
VISIT DATE: 10/22/2021
NARRATIVE
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· Each Staff’s files contain the required health screening as specified in section 101216(g). Licensee/Director understands all personnel, including the Licensee, Administrator and Volunteers, shall be in good health and shall be physically and mentally capable of performing assigned tasks. SEE LIC809D for cited deficiencies
· Personnel that pose a threat to the health and safety of children shall be relieved of their duties.
· All personnel shall be given on-the-job training…or shall have related experience that demonstrates knowledge of and skill in…housekeeping and sanitation principles, including universal health precautions.
· The Licensee/Director shall not exceed the conditions, limitations and capacity specified on the license.
· ZERO TOLERANCE - Appropriate supervision was provided during this inspection. Licensee/Director understands the facility shall ensure no child(ren) shall be left without the supervision, including visual supervision, of a teacher at any time.
· Ratios were met during this inspection. Licensee/Director understands there shall be a ratio of one Teacher supervising no more than 12 children in attendance.
· Licensee/Director shall ensure that each child is accorded a safe, healthful and comfortable accommodations, furnishings and equipment to meet the child's needs.
· The Licensee/Director is responsible for ensuring that children with obvious symptoms of illness including, but not limited to, fever or vomiting, are not accepted.
· The facility is equipped to isolate and care for any child who becomes ill during the day. The front office is used as an isolation area.
· Each child’s file contains the required identification and emergency information and medical assessment.
· Menus shall be posted at least one week in advance in a place visible by the child’s authorized
· AB1207 Mandated Child Abuse Reporter training completed on 01/13/2020 and expires on 01/13/2021 for Director Charlene.
· Review of staff records did not contain proof staff are immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year or provide a statement denying the influenza vaccination. SEE LIC809D for cited deficiencies
· 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.
SUPERVISOR'S NAME: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Destinee HogueTELEPHONE: (951) 218-5196
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021
LIC809 (FAS) - (06/04)
Page: 3 of 9
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: CHILDTIME CHILDREN'S CENTERS
FACILITY NUMBER: 360910507
VISIT DATE: 10/22/2021
NARRATIVE
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- 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/inspection-process.

· The Licensee can submit transfer forms to associate new individuals or to disassociate someone from your facility at: Associations_Disassociations862@dss.ca.gov



· 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

· The Duty Officer is available to answer questions Monday – Friday from 8:00am to 5:00pm at (951)782-4200

· Access to forms & Regulations for a Child Care Center are online at www.cdss.ca.gov.

See LIC809D for cited deficiencies.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS

Exit interview conducted and report was reviewed with the Director, Charlene Bunnell

SUPERVISOR'S NAME: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Destinee HogueTELEPHONE: (951) 218-5196
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021
LIC809 (FAS) - (06/04)
Page: 4 of 9
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: CHILDTIME CHILDREN'S CENTERS
FACILITY NUMBER: 360910507
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101238(g)(1)
Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to children. (1) Storage areas for poisons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on a tour of the Pre-K classroom and Preschool classroom, the licensee did not comply with the section cited above, LPA observed labeled bleach bottles (Bottle #3) stored behind a latched cabinet. At the time of LPA's inspection, children were napping in the Preschool classroom and both cabinets were securely latched. LPA advised Director Bottle #3 and any other toxins and/or poisons must be stored in areas with a key-lock. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2021
Plan of Correction
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During this inspection, Licensee agrees to ensure poisons and toxins are stored behind a locked cabinet/storage area. Licensee agrees to submit proof Bottle #3 in the Pre-K and Preschool classrooms are stored behind locked cabinets/storage areas. Proof can be submitted via email or mail.
Type B
Section Cited
CCR
101238(c)
Buildings and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on inspection of the outdoor play area , the licensee did not comply with the section cited above, based on LPA Hogue observation of the preschool playground had sand and wood chips on the playground equipment, including playground stairs and playground steps. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2021
Plan of Correction
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Licensee agrees to have staff inspect the outdoor play area prior to preschool use and agrees the outdoor play equipment will be free from sand, wood chips, and other debris. Licensee agrees staff will utilize the Daily/Weekly Cleaning/Maintenance log and staff will clean the outdoor play equipment prior to preschool use of the outdoor play area.
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: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Destinee HogueTELEPHONE: (951) 218-5196
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2021
LIC809 (FAS) - (06/04)
Page: 5 of 9
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: CHILDTIME CHILDREN'S CENTERS
FACILITY NUMBER: 360910507
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2021

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 facility records review, Licensee did not have proof of immunizations for Staff #3 and Staff #6 available at the time of LPA's request. Staff #3 is missing proof of MMR and Staff #6 is missing proof of Tdap and MMR. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2021
Plan of Correction
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Licensee agrees to submit proof of immunizations for Staff #3, and Staff #6 via email or mail.
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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Based on facility records review, the licensee did not comply with the section cited above in Licensee did not have proof of AB1207 Mandated Child Abuse certificates for Staff #3, along with renewal certificates for Staff #2 and Staff #4. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2021
Plan of Correction
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Director agrees to submit proof of completed and renewed AB1207 Mandated Child Abuse certificates for Staff #2, Staff #3, and Staff #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: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Destinee HogueTELEPHONE: (951) 218-5196
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2021
LIC809 (FAS) - (06/04)
Page: 6 of 9
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: CHILDTIME CHILDREN'S CENTERS
FACILITY NUMBER: 360910507
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101215.1(m)
Child Care Center Director Qualifications and Duties
(m) A child care center director shall complete 16 hours of health and safety training if necessary pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of facility records, the Licensee did not comply with the section cited above in, Director Charlene Bunnell has proof of completed Health & Safety on college transcripts, however Director has not completed the Lead Exposure component of Health & Safety training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2021
Plan of Correction
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Licensee agrees to have Director Charlene complete Health & Safety Lead Exposure component. Proof of completed training can be submitted via email or mail.
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 review of facility records, the Licensee did not comply with the section cited above in, Director Charlene did not have proof of recent TB clearance. TB clearance on file was not performed within one year prior to hire date or seven days after employment which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2021
Plan of Correction
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Licensee agrees to submit proof of TB clearance for Director Charlene via email or mail.
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: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Destinee HogueTELEPHONE: (951) 218-5196
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2021
LIC809 (FAS) - (06/04)
Page: 7 of 9
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: CHILDTIME CHILDREN'S CENTERS
FACILITY NUMBER: 360910507
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(g)(2)
Personnel Requirements
(2) Each person specified in (g) above shall have a health-screening report signed by the person performing the screening. This report shall indicate the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of facility records, the Licensee did not comply with the section cited above by not having a current proof of LIC503-Health Screening on file for Director Charlene Bunnell and Staff #4 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2021
Plan of Correction
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Licensee agrees to submit an updated LIC503-Health Screening for Director and Staff #4. LIC503 can be submitted via email or mail.
Type B
Section Cited
CCR
101220.1(g)
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on review of facility records, the Licensee did not comply with the section cited above by not having proof of immunizations for Child #1 and Child #7. Licensee did not have updated immunizations for Child #2, Child #3, Child #4, Child #5, Child #8, and Child #10 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2021
Plan of Correction
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2
3
4
Licensee agrees to submit immunizations (CDPH286) for Child #1, Child #2, Child #3, Child #4, Child #5, Child #7, Child #8, and Child #10 via email or mail.
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: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Destinee HogueTELEPHONE: (951) 218-5196
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2021
LIC809 (FAS) - (06/04)
Page: 8 of 9
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: CHILDTIME CHILDREN'S CENTERS
FACILITY NUMBER: 360910507
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8595
(b)(1) A licensed child day care facility shall provide to the parents or guardians of each child receiving services in the facility copies of any licensing report that documents any Type A citation that represents an immediate risk to the health, safety, or personal rights of children in care...(2) Upon enrollment of a new child in a facility, the licensee shall provide to the parents or legal guardians of the newly enrolling child copies of any licensing report that the licensee has received during the prior 12-month period that documents any Type A citation that represents an immediate risk to the health, safety, or personal rights of children in care...

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on review of facility records, the Licensee did not comply with the section cited above by not having proof of LIC9224-Acknowledgement Receipt of Licensing Reports from inspection on 06/17/2021 which a Type A deficiency for Care and Supervision 101229(a)(1). This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2021
Plan of Correction
1
2
3
4
Licensee agrees to ensure currently enrolled and newly enrolled families receive a copy of Type A deficiency cited on June 17, 2021 and agrees to have parents sign LIC9224-Acknowledgement Receipt of Licensing Reports. Licensee agrees to submit LIC9224 for Child #1-Child #10 via email or mail.
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: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Destinee HogueTELEPHONE: (951) 218-5196
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2021
LIC809 (FAS) - (06/04)
Page: 9 of 9