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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304270683
Report Date: 03/26/2024
Date Signed: 03/26/2024 12:44:50 PM

Document Has Been Signed on 03/26/2024 12:44 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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:MAOF CHILD CARE CENTER-SANTA ANAFACILITY NUMBER:
304270683
ADMINISTRATOR:OLIVIA ORTIZFACILITY TYPE:
850
ADDRESS:2033 WEST EDINGER STREETTELEPHONE:
(714) 557-2686
CITY:SANTA ANASTATE: CAZIP CODE:
92704
CAPACITY: 50TOTAL ENROLLED CHILDREN: 50CENSUS: 25DATE:
03/26/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Lynette O'Campo Diaz - Site SupervisorTIME COMPLETED:
01:00 PM
NARRATIVE
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An unannounced case management inspection was conducted on this date by Licensing Program Analyst (LPA) Carmen Odom in response to a self-reported incident dated 3/18/24. Present during today’s inspection was the Site Supervisor, Lynette O’Campo. LPA took a tour of the facility and census was taken in individual classrooms. The overall census observed was 25 preschool age children and 4 staff members.

A review of adult records indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

On 3/18/2024 an Unusual Incident Report was filed with the Department to self-report an incident that occurred on 3/18/2024. Program manager reported on 3/18/24 at 12:00pm Staff #3 (S3) was notified that Child #1 (C1) was complaining that their tooth hurt. C1 told S3 that Staff #1 (S1) pulled C1’s blanket from C1’s mouth and it hurt their tooth. S3 observed C1’s tooth was loose, but it was not bleeding. S1 denied pulling C1’s blanket. Staff #2 (S2) did not observe the incident as they were helping another child fall asleep. S3 dismissed S1 from the facility until further notice.

During the investigation, LPA obtained personnel report, children’s roster, interviewed 2 staff, 1 child and reviewed records obtained. S3 stated on 3/18/24 around 12:20pm S2 asked to speak with S3 regarding an incident that occurred between S1 and C1, C1 was crying. S3 spoke with C1 and C1 disclosed that S1 had pulled the blanket from C1’s mouth and it hurt their tooth. S1 disclosed they were helping C1 with the blanket because the blanket was wet and S1 told C1 to remove the blanket from their mouth. S1 denied hurting C1 in causing the tooth to be loose. S2 disclosed they did not observe the incident because they were assisting another child fall asleep. S2 heard C1 crying a lot and that when S2 went over to check on C1. C1 told S2 that S1 had pulled the blanket from C1’s mouth and their tooth hurt. LPA interviewed C1 and C1 disclosed S1 pulled the blanket hard and it hurt. S3 stated as they were notifying S1 that they were going to be dismissed from the childcare center, S1 returned to the classroom to question C1 in an intimidating tone of voice. Continue to page 2

SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Carmen Odom
LICENSING EVALUATOR SIGNATURE: DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/26/2024
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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: MAOF CHILD CARE CENTER-SANTA ANA
FACILITY NUMBER: 304270683
VISIT DATE: 03/26/2024
NARRATIVE
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S2 stated S1 was using a loud tone of voice when speaking to C1, S1 was mad and C1 seemed scared. S1 was dismissed from the facility until further notice. S3 reported the incident to P1, P1 does not recall C1’s tooth being loose.

Based on the information gathered from the interviews conducted with staff, child and records reviewed. It was determined that S1 pulled the blanket in an aggressive manner and used an intimidating tone of voice with C1. S1 has violated children’s personal rights.

Licensee will be cited under the California Code of Regulations, Title 22, Division 12, Chapter 1, Section - 101223 (a)(3) Personal Rights is being cited on the attached LIC 809D.

This report cites Type A violation and shall be provided to parents/guardians of children currently in enrolled and to parents/guardians of children newly enrolled at the facility during the next 12 months. Parents/guardians must sign Form LIC9224 to be kept in each child's file.

Exit interview was conducted with Site Supervisor Lynette O’Campo. Notice of Site Visit was posted during the inspection. Facility representatives 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. Facility representatives was provided a copy of their appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. First level appeals should be sent to the regional manager to the address listed above.

SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Carmen Odom
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/26/2024 12:44 PM - It Cannot Be Edited


Created By: Carmen Odom On 03/26/2024 at 11:57 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: MAOF CHILD CARE CENTER-SANTA ANA
FACILITY NUMBER: 304270683

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/26/2024
Section Cited
CCR
101223(a)(3)

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101223(a)(3) Personal Rights (a)The licensee shall ensure that each child is accorded the following personal rights: (3)To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion...This requirement was not met as evidenced by:
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Director stated they spoke with staff regarding blankets and children covering their faces, continuing to communicate with children. We will be conducting training on personal rights.
Director will submit a written plan of correction by 3/27/24.
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Based on interviews during today’s inspection S1 pulled the blanket in an aggressive manner and used an intimidating tone of voice with C1. This is an immediate risk to the personal rights to 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:Carmen Odom
LICENSING EVALUATOR SIGNATURE:
DATE: 03/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2024


LIC809 (FAS) - (06/04)
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