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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304270036
Report Date: 11/22/2023
Date Signed: 11/22/2023 11:51:46 AM

Document Has Been Signed on 11/22/2023 11:51 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:FULLERTON FREE PRESCHOOLFACILITY NUMBER:
304270036
ADMINISTRATOR:GUNTER, ANGELAFACILITY TYPE:
850
ADDRESS:2801 BREA BLVD.TELEPHONE:
(714) 529-5544
CITY:FULLERTONSTATE: CAZIP CODE:
92835
CAPACITY: 225TOTAL ENROLLED CHILDREN: 225CENSUS: 20DATE:
11/22/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Assistant Director Tara MazeikaTIME COMPLETED:
10:00 AM
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On 11/22/23 at 8:30am, A case management inspection was conducted today by Licensing Program Analyst (LPA) Chan who met with Assistant Director Tara Mazeika. Director Angela Gunter arrived 15 minutes later. A self-reported incident by the facility was received at the regional office on 11/17/23 which stated that child #1 (C1) got shocked by electrical outlet and sustained electrical burns.

Upon arrival there were 5 staff present and 20 children in care. A review of criminal record clearances indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

During this investigation, LPA interviewed 2 staff and 1 child and obtained a copy of the children attendance that day, children’s roster, personnel summary report, staff clock in and took pictures of the outlet and the injury.

Due to insufficient information available at this time, further investigation is needed. If any deficiencies are observed, disclosed or discovered during today’s visit, they will be addressed and cited at a later date.



Exit interview was conducted with Assistant Director Tara Mazeika. The Notice of Site Visit was posted. Assistant Director was informed that the Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100.

Appeal Rights was explained. A copy of appeal rights (LIC 9058 1/16) was provided and their signatures on this form acknowledges receipt of these rights. First level appeal is to Regional Manager, address is above on the report.

SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Anna Francesca Chan
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2023
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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