304311650-5-15-2024-06-CC-GLUO-D5AUBA-20240515152601

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304311650
Report Date: 05/15/2024
Date Signed: 05/15/2024 03:26:10 PM

Document Has Been Signed on 05/15/2024 03:26 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 CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME:	PEREZ, ANGELLUZ		FACILITY NUMBER:	304311650
ADMINISTRATOR/ DIRECTOR:	PEREZ, ANGELLUZ		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(714) 614-1709
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90621
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 11	DATE:	05/15/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:00 PM
MET WITH:	Licensee Angelluz Perez		TIME VISIT/ INSPECTION COMPLETED:	03:45 PM

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	(Page 1) Licensing Program Analyst (LPA) Giselle Lucero conducted an unannounced case management inspection regarding a self-reported unusual incident that was reported to the department on 04/30/24. Upon arrival LPA Lucero met with Licensee Angelluz Perez. At 12:00 PM, LPA Lucero observed a total of 11 children, which consist of 2 infants and 9 preschool age children with 1 assistant caring for the children in the childcare room and backyard. 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. On 04/30/2024 the facility self-reported that on 04/29/2024 at 11:00 AM, children were outside playing in the backyard and Staff #2 (S2) came inside the day care room and Child #1 (C1) and Child #2 (C2) followed S2. C1 slammed the door behind them resulting in C2, who was behind C1, to get their finger smashed by the door. During the investigation, LPA reviewed incident report, children’s roster, took pictures, interviewed 2 staff members, Parent #1 (P1) and attempted to interview C1 and C2. During staff interviews, Staff #1 (S1) stated on 04/29/2024, they were outside in the backyard for playtime. S1 came inside to use the restroom. S2 stayed outside with the children. S2 heard Child #3 (C3), who was sleeping in the crib, crying inside the daycare room. S2 came inside to check on C3. C1 and C2 followed S2 inside and C1 slammed the door closed behind them. C2 who was behind C1, was crawling up the steps and C2’s hands were located at the bottom door sill, when the door was shut. (continue to page 2)

SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Giselle Lucero
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024

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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: PEREZ, ANGELLUZ	FACILITY NUMBER: 304311650
	VISIT DATE: 05/15/2024

NARRATIVE

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(Page 2)
Door smashed C2’s left ring finger. C2’s skin on their finger was pinched and bled. S1 applied on pressure on C2’s finger and parents were called. C2 was picked up by parents and taken to CHOC hospital. C2 was given antibiotics and had their finger wrapped. C2 is still attending at the child care facility. S1 stated they are going to change the door to a door that closes slowly to prevent accidents.

S2 stated they were outside in the backyard with the children and came inside. C1 and C2 were following S2. C1 shut the door behind them and C2 was crawling up the steps. C2's hand was at the bottom door sill got their finger smashed by the door. C2 was attended to and pressure was applied while parents were contacted. C2 was picked up early and taken to the hospital.

On 05/15/2024, P1 was interviewed. P1 stated they were notified by the facility regarding C2’s injury. P1 came to pick up C2 and took C2 to the hospital. Doctors determined C2 sustained a fracture. A splinter was put on C2’s finger. C2 is still attending the childcare facility.

LPA attempted to interview C1 and C2, however LPA could not interview children due to their age.

The information obtained collaborated with the information reported by the Licensee. Statements made by witnesses indicate that the incident was an accident and S2 was present during the incident. Reporting requirements were met. Based on LPA observations, interviews conducted, and records/documentation reviewed, there is no evidence to support any violation of Title 22 regulations. No Title 22 deficiencies cited during today's inspection.

Exit interview conducted with Licensee Angelluz Perez. A copy of the Appeal Rights (LIC 9058 FAS 01/16) were given and explained. Licensee’s signature on this form acknowledges receipt of the report (LIC 809). The notice shall be posted for 30 consecutive days. Failure to maintain posting as required will result in a $100.00 civil penalty.

End of report

SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Giselle Lucero
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024

LIC809 (FAS) - (06/04)

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