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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304314038
Report Date: 06/20/2024
Date Signed: 06/20/2024 01:28:57 PM

Document Has Been Signed on 06/20/2024 01:28 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:UTHAYAKUMAR, SUBAFACILITY NUMBER:
304314038
ADMINISTRATOR/
DIRECTOR:		UTHAYAKUMAR, SUBAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 292-3882
CITY:LAKE FORESTSTATE: CAZIP CODE:
92679
CAPACITY: 14TOTAL ENROLLED CHILDREN: 10CENSUS: 8DATE:
06/20/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Suba UthayakumarTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA), Thompson conducted a visit for the purpose of a 3 Year Inspection. LPA observed licensee Suba Uthayakumar and assistant Mamata Khandai caring for 9 children inside the family room area. Licensee was operating within the licensed capacity as specified on license. Facility day care hours are 7:30 AM - 5:30 PM, Monday through Friday.

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 with the exception of Mamata Khandai.

Upon arrival at 10:00 a.m. LPA observed Mamata Khandai caring for nine children in the family room area of the home. Mamata stated she has been working at the family child care home since June 01, 2024. Licensee stated Mamata has been helping because her other assistant is on vacation. Licensee was unable to provide LPA with a file for Mamata during the visit.

Licensee was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

During today’s inspection, LPA toured the inside and outside areas identified in the facility sketch as accessible to childcare children. Off limits areas are made inaccessible by means of baby safety locks and safety gates. The licensee has designated the down stairs area for day care children. The designated day care area is the family room.

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SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Dean Thompson
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 9
Document Has Been Signed on 06/20/2024 01:28 PM - It Cannot Be Edited


Created By: Dean Thompson On 06/20/2024 at 11:31 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: UTHAYAKUMAR, SUBA
FACILITY NUMBER: 304314038

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1596.871(c)(1)(A)
Administration of Child Day Care Licensing
Subsequent to initial licensure, a person specified in subdivision (b) who is not exempt from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification, pursuant to subdivision(f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above. Upon arrival at 10:00 a.m. LPA observed Mamata Khandai caring for children in the family room area of the home. Mamata stated she has been working at the family child care home since June 01, 2024 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2024
Plan of Correction
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Licensee stated she will have Mamata Khandai submit fingerprints.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Dean Thompson
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024


LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 06/20/2024 01:28 PM - It Cannot Be Edited


Created By: Dean Thompson On 06/20/2024 at 11:31 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: UTHAYAKUMAR, SUBA
FACILITY NUMBER: 304314038

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above. Licensee was unable to provide LPA with documentation showing a disaster drill has been conducted at least once every six months which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/04/2024
Plan of Correction
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Licensee stated she will submit documentation to LPA by POC due date.
Type B
Section Cited
CCR
102416.1(a)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above. Licensee was unable to provide LPA with a file for Mamata which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/04/2024
Plan of Correction
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Licensee stated she will submit documentation to LPA by POC due date.
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:Dean Thompson
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 06/20/2024 01:28 PM - It Cannot Be Edited


Created By: Dean Thompson On 06/20/2024 at 11:31 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: UTHAYAKUMAR, SUBA
FACILITY NUMBER: 304314038

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above. While reviewing the children files at 10:30 a.m. LPA observed four out of nine children were missing immunization records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/04/2024
Plan of Correction
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Licensee stated she will submit documentation to LPA by POC due date.
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above. Licensee was unable to provide LPA with a current roster for children in care which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/04/2024
Plan of Correction
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Licensee stated she will submit documentation to LPA by POC due date.
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:Dean Thompson
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/20/2024 01:28 PM - It Cannot Be Edited


Created By: Dean Thompson On 06/20/2024 at 11:31 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: UTHAYAKUMAR, SUBA
FACILITY NUMBER: 304314038

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above.
While reviewing the children files at 10:30 a.m. LPA observed six out of nine children were missing LIC 995A Notification of Parents' Rights which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/04/2024
Plan of Correction
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Licensee stated she will submit documentation to LPA by POC due date.

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:Dean Thompson
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 06/20/2024 01:28 PM - It Cannot Be Edited


Created By: Dean Thompson On 06/20/2024 at 11:31 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: UTHAYAKUMAR, SUBA
FACILITY NUMBER: 304314038

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above. Licensee was unable to provide LPA with documentation for child #1 (C1) showing she is checking on infants (24 months and under) every 15 minutes during nap time which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/04/2024
Plan of Correction
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Licensee stated she will submit documentation to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Dean Thompson
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024


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: UTHAYAKUMAR, SUBA
FACILITY NUMBER: 304314038
VISIT DATE: 06/20/2024
NARRATIVE
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The facility has a fireplace inside the family room that is inaccessible to children. There is a working carbon monoxide, smoke detector, and a fire extinguisher in the home that meet statutory and State Fire Marshall standards. Licensee was unable to provide LPA with documentation showing a disaster drill has been conducted at least once every six months. Licensee was reminded to conduct and document drills at least once every six months. Detergents, cleaning compounds, medicines, and other items which could pose a danger if readily available to children were stored inaccessible to children. Licensee stated there are no firearms and/or other dangerous weapons in the facility, and none were observed during today's inspections.

The home has age-appropriate toys for the ages served. LPA verified there is a working telephone service (cellular service). Licensee stated, they use the back yard for outdoor play, LPA inspected the back yard, and it was found to be incompliance. There are no bodies of water at the facility.

Licensee was unable to provide LPA with a current roster for children in care. Children’s records for children present during LPA’s inspection were reviewed for a copy of the emergency information card that contains all the information specified by regulation (LIC 700), Immunization records, Affidavit Regarding Liability Insurance (LIC282), Consent for Emergency Medical Treatment (LIC627), Notification of Parent’s Rights (LIC995A) and found to be not in compliance. While reviewing the children files at 10:30 a.m. LPA observed four out of nine children were missing immunization records and six out of nine children were missing LIC 995A Notification of Parents' Rights. Licensee was unable to provide LPA with documentation for child #1 (C1) showing she is checking on infants (24 months and under) every 15 minutes during nap time.LPA provided a copy of LIC 9227 Individual Infant Sleeping Plan and napping log and reviewed it with licensee.



The licensee Pediatric CPR/First Aid certification expires 7/27/2024. Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a family childcare home if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles for licensee reviewed and within compliance.

Beginning March 31, 2018, H&S Code 1596.8662 requires all licensed providers and employees to complete mandated reporting training, and to renew the training every two years. Licensee AB1207 mandated reporter certification expires 8/23/2024.

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SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Dean Thompson
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC809 (FAS) - (06/04)
Page: 7 of 9
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: UTHAYAKUMAR, SUBA
FACILITY NUMBER: 304314038
VISIT DATE: 06/20/2024
NARRATIVE
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The licensee understands she must be present in the facility and must ensure children in care are always supervised. Children are not to be left alone in parked vehicles. When the licensee is temporarily absent from the facility, arrangements must be made for a qualified substitute adult to care and supervise children while absent. The substitute adult must have the required criminal record, child abuse index clearances, immunizations, Pediatric CPR/First Aid, and mandated reporter training.

CCLD website www.ccld.ca.gov was provided to licensee to access regulations, updates, and licensing forms. Licensee was advised to register through childcareadvocatesprogram@dss.ca.gov in order to receive quarterly updates. Licensee was advised of their responsibility to review the Provider Information Notices (PIN) found on the CCLD website. A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the licensee.



To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.



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SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Dean Thompson
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
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: UTHAYAKUMAR, SUBA
FACILITY NUMBER: 304314038
VISIT DATE: 06/20/2024
NARRATIVE
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Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian

In the areas that were evaluated, one Type A and six Type B deficiencies were observed of the California Code of Regulations, Title 22, Division 12 at the time of the visit. See LIC 809D page for deficiencies.

LPA Thompson informed licensee Suba Uthayakumar that this report dated 6/20/2024 document(s) two Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Thompson informed the licensee Suba Uthayakumar to provide a copy of this licensing report dated 6/20/2024 that documents any Type A citation(s) 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 licensee Suba Uthayakumar. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

During the exit interview, the LICENSEE Suba Uthayakumar, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Appeal Rights were explained. The Licensee was provided a copy of appeal rights (LIC 9058 01/16) 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. First level appeals should be sent to the regional manager to the address listed above.
SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Dean Thompson
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC809 (FAS) - (06/04)
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