364820887-4-4-2025-09-CC-CATN-DFEPYZ-20250404114445

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 364820887
Report Date: 04/04/2025
Date Signed: 04/04/2025 11:45:40 AM

Document Has Been Signed on 04/04/2025 11:45 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME:	KUSDONO FAMILY CHILD CARE		FACILITY NUMBER:	364820887
ADMINISTRATOR/ DIRECTOR:	KUSDONO, MARIE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(909) 597-3106
CITY:	CHINO HILLS	STATE: CA	ZIP CODE:	91709
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 8	DATE:	04/04/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:36 AM
MET WITH:	Juliana Harsojo		TIME VISIT/ INSPECTION COMPLETED:	11:55 AM

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	On date and time listed above, Licensing Program Analyst (LPA) Chase Atherton arrived at the facility to conduct a required 3-year inspection. LPA was granted entry by Assistant acting as the Facility Representative, Juliana Harsojo. LPA toured the facility, inside and out, reviewed records, and observed and/or discussed the following: Days and hours of operation are Monday- Friday, 8:15 am - 12:15 pm for the morning class and 1pm to 5pm for the afternoon session OFF-LIMIT AREAS INCLUDE: The entire interior of the house except for the garage, the laundry room, and the small hallway that leads to the toilet the children use. The inspection consisted of reviews of the CARE tool domains. The inspection found the facility to be in compliance except as noted on the LIC809D. Deficiencies were cited this visit. The facility is operating within the licensed capacity and appropriate ratios. Licensee is NOT present in the home, but appropriate supervision is provided. At 8:36 am LPA observed the Licensee was absent from the facility. LPA interviewed Staff 1 (S1) at 8:40 am which revealed that the Licensee is "out of town, on a trip." LPA interview S2 at 9:28 am which revealed that the Licensee will be back tonight. LPA interviewed S1 at 10:13 am which revealed that the Licensee has been absent for all of 4/3/2025 and today 4/4/2025. This does not comply with Title 22 Regulations in that the Licensee is allowed to be temporarily absent from the facility for only 20% of the operating hours, per day. SEE LIC809D for deficiency cited. A working telephone is present. Cellphone Appropriate fire extinguisher is present. Smoke and carbon monoxide detectors are present and were tested by the Facility Representative during this inspection. All hazardous items are inaccessible which could pose a danger to children.

Ana Noble	TELEPHONE: (951) 782-3278
Chase Atherton	TELEPHONE: (951) 970-1161
	DATE: 04/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025

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 6

California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

Page: 2 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: KUSDONO FAMILY CHILD CARE	FACILITY NUMBER: 364820887
	VISIT DATE: 04/04/2025

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
26
27
28
29
30
31
32

Storage of poisons/toxins are NOT locked. At 8:54 am LPA observed cleaning solutions that note to call poison control if ingested in an area accessible to children, but out of their reach. At 8:57 am LPA observed cleaning solutions that note to call poison control if ingested in an area accessible to children, but out of their reach. At 9:10 am LPA observed 3 liquids that note to call poison control if ingested in an area the children use, but the area was not accessible to children at the time. All items listed above are considered "poisons" and therefore are required to be in a storage area that is locked. S1 and S2 removed the items that are considered poisons and stored them in an off limits area, inaccessible to children, bringing the facility back into compliance during this visit. SEE LIC809D for deficiency cited.
No fireplace. Stairs are properly barricaded: Yes, stairs are inaccessible to children.
Facility is clean, orderly and has adequate heating and ventilation.
Facility has safe and age-appropriate toys for both indoor and outdoor activities.
Outdoor play area is fenced.
Verification of control of property on file.
License, Emergency Disaster Plan (LIC610) and Earthquake Preparedness Checklist (LIC9148) Parent’s Rights Poster (PUB393), and Personal Rights are posted.
Pediatric CPR and First Aid Card expires on: 8/2026 S1
Health & Safety Certificate - completed on: No one is present with a Health and Safety certificate, as the Licensee is not present. This missing requirement is covered under an earlier deficiency cited.
Mandated reporter expires: 10/2026 S1
Fire clearance: 12/08/2010
Documentation of fire & earthquake completed. Last drill: 2/2025
Children’s records are complete.
Employee records are complete.
No guns or weapons present as stated by the Facility Representative. Facility Representative understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 regulations.
There are no bodies of water during this visit. Facility Representative understands all bodies of water must be properly covered or fenced per Title 22 regulations. The Department must be notified before and after installation of the above types of bodies of water.

Additionally, the following was reviewed with Facility Representative.

SUPERVISOR'S NAME: Ana Noble	TELEPHONE: (951) 782-3278
LICENSING EVALUATOR NAME: Chase Atherton	TELEPHONE: (951) 970-1161
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025

LIC809 (FAS) - (06/04)

Page: 3 of 6

Document Has Been Signed on 04/04/2025 11:45 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: KUSDONO FAMILY CHILD CARE	FACILITY NUMBER: 364820887
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

102417(g)(4)(A)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children. (A) Storage areas for poisons, firearms and other dangerous weapons shall be locked. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, there were cleaning liquids and other items that noted to call poison control if ingested in areas accessible to children in the daycare room, bathroom, and shed in the backyard, but out of reach of children. The storage areas where these were located were not locked which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/09/2025
	Plan of Correction
1 2 3 4	Facility Representative moved all items to an off limits area inaccessible to children during thsi visit. Licensee will submit proof (pictures) of all listed poisons moved to a storage area that is locked with either a key lock or combination lock to the Department by the POC due date.

Type B

Section Cited

CCR

102417(a)

Operation of A Family Child Care Home

(a) The licensee shall be present in the home and shall ensure that children in care are supervised at all times. When circumstances require the licensee to be temporarily absent from the home, the licensee shall arrange for a substitute adult to care for and supervise the children during his/her absence. Temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in the licensee was not present for 2 days which is more than the allowed temporary absence of 20% of the hours that the facility is providing care per day, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/09/2025
	Plan of Correction
1 2 3 4	Licensee will submit a written statement (signed and dated) that acknowledges their understanding of California Code of Regulations section 102417(a). Licensee will also submit a written statement (signed and dated) detailing what steps they will take in the event they need to temporarily close their facility due to their extended absence.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Ana Noble	TELEPHONE: (951) 782-3278
Chase Atherton	TELEPHONE: (951) 970-1161
	DATE: 04/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025

LIC809 (FAS) - (06/04)

Page: 4 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: KUSDONO FAMILY CHILD CARE	FACILITY NUMBER: 364820887
	VISIT DATE: 04/04/2025

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
26
27
28
29
30
31
32

- AB 1207 – Mandated Child Abuse Reporting: Child Day Care Personnel Training, beginning January 1, 2018 – Requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years.

AB2960 – Childcare and development services, online portal – Effective June 20, 2022 - This bill requires the State Superintendent of Public Instruction (SSPI), within the California Department of Education (CDE), to develop and post on CDE's website a comprehensive child care and development services online portal for families and providers by June 30, 2022.
- Effective January 1, 2017 – Children under 2 years of age shall ride in a rear-facing car seat unless the child weighs 40 or more pounds OR is 40 or more inches tall. For additional information regarding car seat laws see www.chp.ca.gov
-Facility Representative provided the Unusual Incident Reporting email: UnusualIncidentReportsDO09@dss.ca.gov
-The Duty Officer is available to answer questions Mon. – Fri. at 1-844-LET-US-NO (1-844-538-8766)
-Access to forms & Regulations for Family Child Care Homes online at www.ccld.ca.gov
-There is a responsibility to know the regulations for anyone providing care.
-Failure to meet the posting requirements shall result in an immediate civil penalty

To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication

MyChildCarePlan.org – Centers and Family Child Care Homes Facility Representative was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. 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: https://www.ada.gov/resources/child-care-centers/.

SUPERVISOR'S NAME: Ana Noble	TELEPHONE: (951) 782-3278
LICENSING EVALUATOR NAME: Chase Atherton	TELEPHONE: (951) 970-1161
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025

LIC809 (FAS) - (06/04)

Page: 5 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: KUSDONO FAMILY CHILD CARE	FACILITY NUMBER: 364820887
	VISIT DATE: 04/04/2025

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
26
27
28
29
30
31
32

Facility Representative was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with Facility Representative and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe sleep as an additional resource. LPA also informed Facility Representative 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.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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.
During the exit interview, the Facility Representative Juliana Harsojo, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.
Exit interview conducted and report was reviewed with the Facility Representative Juliana Harsojo.
A notice of site visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Ana Noble	TELEPHONE: (951) 782-3278
LICENSING EVALUATOR NAME: Chase Atherton	TELEPHONE: (951) 970-1161
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2025

LIC809 (FAS) - (06/04)

Page: 6 of 6