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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 12:06:04 PM

Document Has Been Signed on 11/22/2023 12:06 PM - 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:
10:01 AM
MET WITH:Assitant Director Tara MizeikaTIME COMPLETED:
12:25 PM
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On 11/22/23, A case management inspection was conducted today by Licensing Program Analyst (LPA) Chan who met with Assistant Director Tara Mazeika. A self-reported incident by the facility was received at the regional office on 11/20/23 which stated that Child #1 (C1) was left in the playground unsupervised for about 2 minutes around 12:50pm

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 obtained a copy of the children roster, personnel summary report, children sign in 11/20/23, staff sign in and out 11/20/23. From the interviews conducted it was discovered that on 11/20/23 at around 12:50pm, during transition from outdoor play, children head into the classroom. Staff #1 (S1) lined up the children by the wall. At that time, S1 confirmed that the Aide was inside the classroom changing diaper of 1 child. S1 lined up 8 children by the wall and waited for 3 other children who were walking towards the classroom from the playground. S1 stated that S1 counted the heads of 8 children as they walk inside the classroom. S1 stated that S1’s foot was by the door waiting for the other 3 children to walk in. As S1 was waiting for the 3 other children, S1 noticed 1 child banging the door of the cabinet inside the classroom. While S1 was standing by the door, S1 tried to stop the child inside and S1 stated she was distracted and did not see C1 go out. The other 3 children got inside, and the half door was closed. S1 stated she failed to do a re-count of the children inside. Meanwhile, Staff #2 (S2) was walking out from the preschool office which is across from the playground, and saw C1 standing outside the door of the classroom A-105 parallel to the office door. S2 walked towards C1 and S2 walked C1 inside the classroom A-105. When S1 asked C1 what happened, C1 just bit C1 fingernails and did not respond. It was approximately 2 minutes that C1 was left outside unsupervised. C1's Parents were notified by the Admin about the incident right away.

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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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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: FULLERTON FREE PRESCHOOL
FACILITY NUMBER: 304270036
VISIT DATE: 11/22/2023
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Furthermore, during today's investigation, LPA attempted to interview C1. C1 is non-verbal and shied away from LPA. No information were gathered from C1.

Based on the information gathered from the interviews conducted, it was determined that C1 was left outside by the playground unsupervised for about 2 minutes at 12:50pm on 11/20/23.

The facility was not in compliance of the California Code of Regulations, Title 22, Division 12. The following citation Responsibility for Providing Care and Supervision section 101229(a)(1) was issued today on the attached LIC 809D.

LPA Chan informed Assistant Director Tara Mazeika that this report dated 11/22/23 document 1, Type A citation which shall be posted for 30 consecutive days as there is immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Chan informed the Assistant Director Tara Mazeika to provide a copy of this licensing report dated 11/22/2023 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Exit interview conducted and report was reviewed with the Assistant Director Tara Mazeika. A notice of site visit was given and must remain posted for 30 days.



Appeal Rights and deficiencies were discussed. The facility representative was provided a copy of their appeal rights (LIC 9058) 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.
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
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/22/2023 12:06 PM - It Cannot Be Edited


Created By: Anna Francesca Chan On 11/22/2023 at 11:25 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: FULLERTON FREE PRESCHOOL
FACILITY NUMBER: 304270036

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/27/2023
Section Cited
CCR
101229(a)(1)

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Responsibility for Providing Care and Supervision 101229(a)(1): No child(ren) shall be left without the supervision, including visual observation, of a teacher at any time except as specified in sections 101216.2(e)(1) and 101230(c)(1).

This requirement is not met as evidenced by:
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The facility will submit a written plan to ensure children are not left unsupervised. Written plan to be submitted via email or text message by the due date of 11/27/23
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Based on the information gathered from the interviews conducted, It was determined that C1 was left outside by the playground unsupervised for about 2 minutes.

This is an immediate risk to the health and safety of the children in care.
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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:Judy Hanson
LICENSING EVALUATOR NAME:Anna Francesca Chan
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2023


LIC809 (FAS) - (06/04)
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