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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304310410
Report Date: 02/05/2025
Date Signed: 02/05/2025 11:59:23 AM

Document Has Been Signed on 02/05/2025 11:59 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:LUPERCIO, GUADALUPEFACILITY NUMBER:
304310410
ADMINISTRATOR/
DIRECTOR:		LUPERCIO, GUADALUPEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 641-4756
CITY:SANTA ANASTATE: CAZIP CODE:
92707
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 6DATE:
02/05/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Lupercio GuadalupeTIME VISIT/
INSPECTION COMPLETED:
12:01 PM
NARRATIVE
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On 2/5/2025, Licensing Program Analyst (LPA) A. Silva conducted a Case Management – Deficiencies to address reporting requirements deficiencies at the family day care home. Upon arrival, the LPA met with Licensee Guadalupe Lupercio. An on-site Facility Personnel Report Summary review indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Census was six children. The facility was operating within ratios and capacity.

On 9/26/2024, the LPA received a copy of the local law enforcement report about the investigation of the allegation that a daycare child was touched inappropriately while in care, which as been investigated and documented on complaint investigation report dated 02/05/24. The local law enforcement report shows that on 9/03/24 law enforcement agents interviewed daycare staff S1, S2, S3, and S4 at the daycare about the allegation. The licensee failed to report this incident to the licensing department.

On 9/27/2024, the licensee provided video footage from surveillance cameras installed in the front of the home. Upon review, the LPA observed the footage was dated 9/6/2024. The footage shows Parent #1 (P1) and the licensee talking in the front of the licensed home. No audio was available. According to the licensee, Parent #1 was at the daycare discussing the aforementioned allegation with the licensee. The licensee failed to report this incident to the licensing department.

Based on interview statements, video footage and on the records reviewed, the licensee failed to report an unusual incident event. According to Health and Safety Code 1597.467(b)(1)(C) Injury or acts of violence reporting requirements: (b)(1) A report shall be made to the department … following the occurrence during the operation of a family day care home of any of the following events: (C) Any unusual incident or child absence that threatens the physical or emotional health or safety of any child.
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Archibaldo Silva
LICENSING EVALUATOR SIGNATURE: DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/05/2025
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: LUPERCIO, GUADALUPE
FACILITY NUMBER: 304310410
VISIT DATE: 02/05/2025
NARRATIVE
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LPA A. Silva informed licensee Guadalupe Lupercio that this licensing report dated 2/5/25 documents one “Type A” citation(s). Type A citation(s) must be posted for 30 consecutive days during the hours that children are in care as there is/are immediate risk(s) to the health, safety, or personal rights of children in care. LPA A. Silva further informed licensee Lupercio that a copy of this licensing report must be provided to parents or guardians of all clients currently enrolled by the next business day or by the next day the children are in care, a copy of this report must be provided to the parents or guardians of all newly enrolled clients for 12 months from the date of this report, a signed Acknowledgement of Receipt of Licensing Report (LIC 9224) form, or another written equivalent statement, must be placed in the child's file for verification of receipt of the report.

Appeal Rights 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. A notice of site visit was provided and must remain posted for 30 days. Exit interview conducted and report was reviewed with the daycare representative.

END.

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Archibaldo Silva
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/05/2025 11:59 AM - It Cannot Be Edited


Created By: Archibaldo Silva On 02/05/2025 at 11:49 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: LUPERCIO, GUADALUPE
FACILITY NUMBER: 304310410

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/06/2025
Section Cited
HSC
1597.467(b)(1)(C)

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1597.467(b)(1)(C) Injury or acts of violence reporting requirements (b)(1) A report shall be made to the department … following .. (C) Any unusual incident that threatens the physical or emotional health or safety of any child. This requirement is not met as evidenced by:
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The licensee will adhere to the reporting requirements, including reporting to parents a Type A deficiency. The licensee will keep the LIC9224 in the children's files.
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Based on records reviewed, video fottage, and interview statements, the licensee failed to report an unusual incident to the licensing Department in two separate occasions. This poses an imediate risk to the health, safety, and personal rights of 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:Thuy Ho
LICENSING EVALUATOR NAME:Archibaldo Silva
LICENSING EVALUATOR SIGNATURE:
DATE: 02/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2025


LIC809 (FAS) - (06/04)
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