300610744-10-20-2023-06-CC-AFCN-CWSNAJ-20231020101738

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 300610744
Report Date: 10/20/2023
Date Signed: 10/20/2023 10:17:44 AM

Document Has Been Signed on 10/20/2023 10:17 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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME:	GREEN, DONNA		FACILITY NUMBER:	300610744
ADMINISTRATOR:	GREEN, DONNA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(714) 814-2225
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92808
CAPACITY: 12	TOTAL ENROLLED CHILDREN: 12	CENSUS: 5	DATE:	10/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Licensee Donna Green		TIME COMPLETED:	10:30 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 10/20/23, an unannounced Annual Random inspection was conducted at the facility by Licensing Program Analyst (LPA) Anna Chan. At 8:40am, LPA observed licensee Donna Green, caring for 4 preschool children. At 9am 1 infant was dropped off. Children are playing outside at the backyard when LPA arrived. Licensee was operating within the licensed capacity as specified on license. A review of the Facility Personnel Report Summary on this date indicates all facility residents, staff, or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Currently there are 2 adults including the licensee living in the facility. Facility Day care hours are 7:00am-5:00pm, Monday through Friday. During today’s inspection, LPA and licensee Donna Green toured the inside and outside areas identified in the facility sketch as accessible to childcare children. Off limits areas are made inaccessible by means baby gates. The childcare area includes the family room which is the day care area and it is accessed through the living room, 1 bedroom that is also a childcare area and nap area, 1 bathroom and backyard for outside play area. There are working carbon monoxide, smoke detector, and fire extinguishers in the home that meet statutory and State Fire Marshall standards. Detergents, cleaning compounds, medicines, and other items which could pose a danger to children were stored inaccessible to children. There were no poisons or other items observed which could pose a danger to children. Licensee stated there are no firearms and/or other dangerous weapons in the facility and none were observed during today's inspections. There is a fireplace in the living room screened by a 4-panel mesh screen inside and covered by another 4-panel glass door and inaccessible to children in care. The home has age-appropriate toys for the ages served. Page 1 of 3

SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Anna Francesca Chan
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: GREEN, DONNA	FACILITY NUMBER: 300610744
	VISIT DATE: 10/20/2023

NARRATIVE

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LPA verified there is a working telephone service (landline and cellular service), licensee was reminded that childcare phone needs to always remain the in the childcare. There are no bodies of water on the premises.

The licensee does have a current roster of children in care. 5 Children’s records for children present during LPA’s inspection were reviewed for a copy of the emergency information card that contains all the information specified by regulation (LIC 700), Immunization records, Affidavit Regarding Liability Insurance (LIC282), Consent for Emergency Medical Treatment (LIC627), Notification of Parent’s Rights (LIC995A) and found to be in compliance. Licensee stated, there are 2 infant under 24 months enrolled in the childcare. LPA reviewed LIC 9227 Individual Infant Sleeping Plan and napping log for infants.

The licensee’s Pediatric CPR/First Aid certification expires on 11/2024. Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a family childcare home if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles for both licensee and assistant were reviewed and within compliance.
Beginning March 31, 2018, H&S Code 1596.8662 requires all licensed providers and employees to complete mandated reporting training, and to renew the training every two years.

LICENSEE WILL WAIT UNTIL FACILITY OPENS TO DETERMINE IMS NEEDS:
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: http://www.ada.gov/childqanda.htm

The licensee understands she must be present in the facility and must ensure children in care are always supervised. Children are not to be left alone in parked vehicles. When the licensee is temporarily absent from the facility, arrangements must be made for a qualified substitute adult to care and supervise children while absent. The substitute adult must have the required criminal record, child abuse index clearances, immunizations, Pediatric CPR/First Aid, and mandated reporter training. LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian
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SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Anna Francesca Chan
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: GREEN, DONNA	FACILITY NUMBER: 300610744
	VISIT DATE: 10/20/2023

NARRATIVE

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CCLD website www.cdss.ca.gov/inforesources/community-care-licensing was provided to licensee to access regulations, updates, and licensing forms. Licensee was advised to register through childcareadvocatesprogram@dss.ca.gov in order to receive quarterly updates. Licensee was advised of their responsibility to review the Provider Information Notices (PIN) found on the CCLD website. A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the licensee.

LPA discussed the safe sleep regulations with licensee 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 licensee [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.

In the areas that were evaluated, NO deficiencies were observed of the California Code of Regulations, Title 22, Division 12 at the time of the visit.

Licensee was reminded that all adults 18 and over living or working in the home, 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 licensed Family Child Care Home. 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.

Exit interview conducted and report was reviewed with the licensee Donna Green. A notice of site visit was posted and must remain posted for 30 days.

Appeal Rights were explained. The Licensee was provided a copy of appeal rights (LIC 9058 03/2022) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. First level appeals should be sent to the regional manager to the address listed above.

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SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Anna Francesca Chan
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

LIC809 (FAS) - (06/04)

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