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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304312897
Report Date: 02/11/2025
Date Signed: 02/11/2025 04:24:37 PM

Document Has Been Signed on 02/11/2025 04:24 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:KELLY, MATTHEW DEANFACILITY NUMBER:
304312897
ADMINISTRATOR/
DIRECTOR:		KELLY, MATTHEW DEANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 624-3780
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
02/11/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:55 PM
MET WITH:Licensee, Kelly Matthew Dean TIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPAs) Aiddee Nunez and Susan Deschampe conducted an unannounced case management incident inspection in response to a self-report Unusual Incident dated 11/12/2024 and 2/5/2025. During today’s visit, LPAs met with licensee Matthew Dean Kelly. LPA observed 1 school age child and the licensee present in the home.

During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staffing ratios. A review of the Facility Personnel Report Summary on this date indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

On 11/12/2024, a self-reported Unusual Incident Report (UIR) was filed with the Licensing Office of an incident that happened on 11/6/2024 or 11/7/2024 Staff#1(S1) did not know the exact date. On 11/11/2024, S1 met with Parent#1 (P1) and P1 had come across an inappropriate video while looking at Child#1 (C1) tablet. It showed C1 and Child#2 (C2) dancing suggestively and it showed C1 putting a ruler between C1 bottom cheeks on the outside of C1’s clothing and continue to dance. Then it showed C1 pulling down C1 pants and C2 putting a ruler between her bare bottom cheeks. S1 stated S1 was sitting on the living room sofas watching the rest of the children while C1 and C2 were in the dining room where there is a picnic table using the tablet. S1 stated children are able to use their tablets once they are done with homework. S1 stated C1 is no longer enrolled at the facility and C2 was terminated from the program. On 11/19/2024 LPA Nunez interviewed 4 children and no concerns were disclosed.


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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Aiddee Nunez
LICENSING EVALUATOR SIGNATURE: DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/11/2025
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: KELLY, MATTHEW DEAN
FACILITY NUMBER: 304312897
VISIT DATE: 02/11/2025
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On 2/5/2025 a self-reported Unusual Incident Report (UIR) was filed with Licensing Office stating that on 2/4/2025 Child#3 (C3) came to talk to Staff#2 (S2) and told S2 that Child#4 (C4) was touching C3 inappropriately. S2 then called S1 and C3 into the room and told S1 that C4 had touch C3 inappropriately. C3 stated C3 had told C4 to stop and C4 did not. S1 stated C3 stated that the incident happened when S2 was driving the 14 passenger van. When the incident occurred, it was only C3 and C4 in the van with S2. C3 and C4 were in the 2nd row of the van. S2 stated S2 did not observed anything. C3 told S1 and S2 that C4 had touched C3 in the past, but could not recall a date, C3 did not tell anybody about the incident. C4 confirmed that C4 had touched C3 inappropriately twice.

Therefore, in the areas that were inspected, one Type A deficiency was observed of the California Code of Regulations, Title 22, Division 12 Section 102417(a) Operation of A Family Child Care Home. See attached LIC809D

LPA Nunez informed facility representative, that this report dated 1/22/2025 documents one 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.

LPA Nunez also informed the facility representative to provide a copy of this licensing report dated 2/11/2025, 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 was conducted. The Notice of Site Visit was posted for no less than 30 consecutive days. 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.



End of Report.

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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Aiddee Nunez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2025
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/11/2025 04:24 PM - It Cannot Be Edited


Created By: Aiddee Nunez On 02/11/2025 at 03:54 PM
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: KELLY, MATTHEW DEAN
FACILITY NUMBER: 304312897

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/12/2025
Section Cited
CCR
102417(a)

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102417 Operation of A Family Child Care Home (a) The licensee shall be present in the home and shall ensure that children in care are supervised at all times.

This requirement is not met as evidence by:
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Per licensee, he will submit a written plan by POC Due Date stating the changes made and a statement stating the Facility understands the importance of Visual Care and Supervision. Also, the children cannot sit in the same row and boys and girls will be seperated in the van. S2 and C4 will be moving out of the home.
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Based on record reviews and interviews C4 touched inappropriately C3. This is an immediate risk to the 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:Thuy Ho
LICENSING EVALUATOR NAME:Aiddee Nunez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2025


LIC809 (FAS) - (06/04)
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