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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304314125
Report Date: 06/21/2023
Date Signed: 06/21/2023 12:48:44 PM

Document Has Been Signed on 06/21/2023 12:48 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:DUQUE GONZALEZ, LORNAFACILITY NUMBER:
304314125
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 7DATE:
06/21/2023
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Lorna DuqueTIME COMPLETED:
01:20 PM
NARRATIVE
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On June 21, 2023, Licensing Program Analyst (LPA) A. Silva conducted an unannounced Annual/Random inspection assisted by licensee Lorna Duque. Upon arrival, the licensee had seven clients in care, including 2 infants, 4 preschool children, and 1 school-age child. An on-site Facility Personnel Report Summary review showed that all facility residents, staff, or other individuals who require background checks have received criminal record and child abuse index clearances or exemptions, except for Elvia Garcia (See 809D pages). There are 4 adults, including the licensee, currently live in the home. The facility was not in compliance. Violations of the California Code of Regulations, Title 22, Division 12 are listed at the bottom of this licensing report and documented in the 809D form(s) attached.

INDOOR INSPECTION. The LPA inspected the indoor FCCH area identified in the Facility Sketch LIC999 and areas accessible to clients. Off-limits areas were inaccessible to clients in care by means of child gates and locks, at the time of inspection. The facility was equipped with working carbon monoxide and smoke detectors, working telephone service, and at least one fire extinguisher that meets statutory and State Fire Marshall standards. The licensee agrees to maintain telephone service in the home when clients are in care. The licensee is aware that each FCCH shall conduct fire drills and disaster drills at least once every six months. No fireplace in the facility.

The licensee stated that there are no firearms and/or other dangerous weapons in the facility; none were observed during the inspection. Detergents, cleaning compounds, medicines, and other items that could pose a danger if readily available were inaccessible to clients in care. No poisons or other items that could pose a danger to clients were observed during the inspection. Clients nap on cots. Infants nap in play yards. Upon arrival, the LPA observed three play yards with loose articles inside. The deficiency was cited in the 809D pages attached. The LPA observed a car seat in the living room and soon learned that a child was sitting in the car seat. The licensee stated that the child had just been dropped off. The LPA explained that car seats shall be used for transportation purposes only and the deficiency was cited (See 809D).
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Archibaldo Silva
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2023
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 10
Document Has Been Signed on 06/21/2023 12:48 PM - It Cannot Be Edited


Created By: Archibaldo Silva On 06/21/2023 at 10:35 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: DUQUE GONZALEZ, LORNA
FACILITY NUMBER: 304314125

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102425(b)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the licensee did not comply with the section cited above in two out of three play yards, which poses an immediate health, safety or personal rights risk to persons in care. The LPA observed the play yards contained loose articles. One child was sleeping in one of the play yards. An infant was taken out of a car seat and placed inside a play yard with a pillow and a blanket.
POC Due Date: 06/22/2023
Plan of Correction
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The licensee removed the loose articles while the LPA was still in the facility.
Type A
Section Cited
CCR
102425(h)
Infant Safe Sleep
Car seats shall only be used for transportation purposes and shall not be used for sleeping.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in one out of two infants in care, which poses an immediate health, safety or personal rights risk to persons in care. Upon arrival, the LPA observed an infant in a car seat. The car seat with the infant was in the living room with a school age child. The licensee stated the infant's mother had just dropped off the infant.
POC Due Date: 06/22/2023
Plan of Correction
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The licensee removed the infant from the car seat and placed the infant inside a play yard.
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:Patricia Magana
LICENSING EVALUATOR NAME:Archibaldo Silva
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2023


LIC809 (FAS) - (06/04)
Page: 2 of 10
Document Has Been Signed on 06/21/2023 12:48 PM - It Cannot Be Edited


Created By: Archibaldo Silva On 06/21/2023 at 10:35 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: DUQUE GONZALEZ, LORNA
FACILITY NUMBER: 304314125

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and records review, the licensee did not comply with the section cited above in two out of two infants. which poses an immediate health, safety or personal rights risk to persons in care. The licensee stated she could not find the logs she had completed for the infants. The licensee had logs for another child that is not an infant anymore.
POC Due Date: 07/28/2023
Plan of Correction
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The licensee agrees to physically check on the infant every 15 minutes and log it as required by regulations. The licensee will provide proof of correction to the LPA via email by the POC due date above.
Type A
Section Cited
CCR
102370(d)
Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and records review, the licensee did not comply with the section cited above in one out of four adults living in the home, which poses an immediate health, safety or personal rights risk to persons in care. The licensee stated that she provided evidence of clearance to the Department and stated that Elvia Garcia was cleared to be in the home according to another LPA. The LPA reviewed Guardian and the application showed as pending.
POC Due Date: 06/28/2023
Plan of Correction
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The licensee stated that she will ask Elvia Garcia to temporarily stay with her sister and ensure that Elvia receives clearance before returning to the home.
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:Patricia Magana
LICENSING EVALUATOR NAME:Archibaldo Silva
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2023


LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 06/21/2023 12:48 PM - It Cannot Be Edited


Created By: Archibaldo Silva On 06/21/2023 at 10:35 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: DUQUE GONZALEZ, LORNA
FACILITY NUMBER: 304314125

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and records review, the licensee did not comply with the section cited above in four out of four children in care, which poses/posed a potential health, safety or personal rights risk to persons in care. The licensee had the names of two different sets of siblings in a single emergency card LIC700.
POC Due Date: 07/28/2023
Plan of Correction
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The licensee stated she will provide the necessary documents to the parents so that each child has a complete, separate LIC700 in their individual separate files.
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:Patricia Magana
LICENSING EVALUATOR NAME:Archibaldo Silva
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2023


LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 06/21/2023 12:48 PM - It Cannot Be Edited


Created By: Archibaldo Silva On 06/21/2023 at 10:35 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: DUQUE GONZALEZ, LORNA
FACILITY NUMBER: 304314125

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2023

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 and records review, the licensee did not comply with the section cited above in seven out of seven children in care, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/28/2023
Plan of Correction
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The licensee stated she will provide the documents to the parents, have them sign and keep the bottom section of the LIC995A in the children's files.

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:Patricia Magana
LICENSING EVALUATOR NAME:Archibaldo Silva
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2023


LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 06/21/2023 12:48 PM - It Cannot Be Edited


Created By: Archibaldo Silva On 06/21/2023 at 10:35 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: DUQUE GONZALEZ, LORNA
FACILITY NUMBER: 304314125

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and records review, the licensee did not comply with the section cited above in four out of seven children in care, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/28/2023
Plan of Correction
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The licensee stated she will provide the documents to the parents so they can sign/date the forms and then place them in the children's files. The licensee will provide proof of correction by the due date via email.
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and records review, the licensee did not comply with the section cited above in one out of two infants in care, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/28/2023
Plan of Correction
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The licensee stated she will have the parent to complete the LIC9227 and place it in the infant's file.
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:Patricia Magana
LICENSING EVALUATOR NAME:Archibaldo Silva
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2023


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: DUQUE GONZALEZ, LORNA
FACILITY NUMBER: 304314125
VISIT DATE: 06/21/2023
NARRATIVE
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ON-SITE FOOD PREPARATION: The licensee provides snacks to the children. At the time of inspection, food prep areas were clean and sanitary, and food was properly stored. Filtered drinking water is available to clients in care. The LPA observed that the facility’s floors, equipment, furniture, and clients’ bathrooms were clean and in good repair.
OUTDOOR INSPECTION: The playground was enclosed by a fence. The outdoor equipment and toys were in good repair and free of sharp edges. At the time of inspection, the surface of the outdoor activity area was well-maintained and free of any observable hazards There were no bodies of water] (in-ground pool/ jacuzzi/ community pool/water fountain) in the facility at the time of inspection.
PERSONNEL RECORDS: The licensee’s mandated reporter and the Pediatric CPR/First Aid certification were verified.
CHILDRENS’ RECORDS: The licensee has a current roster of clients. The LPA reviewed files for seven clients. The files were in in compliance. Missing or incomplete forms include LIC627, LIC700, LIC995. The licensee had multiple siblings in a single LIC700. The deficiencies were cited in the 809D pages attached.

The Incidental Medical Services (IMS) policy was discussed. A link to PIN 22-02-CCP was provided here: PIN 22-02-CCP: Best Practices Related to the Provision of Incidental Medical Services in Child Care Centers and Family Child. 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 the publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

The licensee understands that he or she shall be present in the home and shall ensure that children in care are supervised at all times. When circumstances require the licensee to be temporarily absent from the home, the licensee shall arrange for a qualified substitute adult to care for and supervise the children during his/her absence [A qualified substitute adult is an adult that has criminal record and child abuse index clearances, immunizations, and current Pediatric CPR/First Aid and Mandated Reporter training]. Temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day, in accordance with Section 102417 of the California Code of Regulations. The licensee understands that children are not to be left alone in parked vehicles.
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Archibaldo Silva
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023
LIC809 (FAS) - (06/04)
Page: 7 of 10
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: DUQUE GONZALEZ, LORNA
FACILITY NUMBER: 304314125
VISIT DATE: 06/21/2023
NARRATIVE
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The licensee understands that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption prior to the initial presence in a licensed child care facility. Violation of this requirement will result in a citation of a deficiency and civil penalties of one hundred dollars ($100) per violation per day for a maximum of five (5) days. Subsequent violations within a twelve (12) month period will result in a civil penalty of one hundred dollars ($100) per violation per day for a maximum of thirty (30) days in accordance with Section 1596.871 of the Health and Safety Code.

The licensee understands that a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year, in accordance with Section 1597.622 of the Health and Safety Code.

The licensee understands it is his or her responsibility to review the Provider Information Notices (PIN) found on the CCLD website above. If not yet registered, the licensee agrees to register to receive quarterly updates via email at childcareadvocatesprogram@dss.ca.gov or online at https://cdss.ca.gov/inforesources/community-care-licensing/subscribe

The LPA discussed the following resources with the licensee:
  1. US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514- 0383 (TTY)
  2. Commonly Asked Questions about Child Care Centers and the ADA link: http://www.ada.gov/childqanda.htm
  3. CaSocialService YouTube Guardian Webinar “All Providers Webinar 12/20/22” link https://youtu.be/WNc1kYmlW9s
  4. Guardian information link: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian
  5. CCLD link: www.cdss.ca.gov/inforesources/community-care-licensing
  6. CPSC (United States Consumer Product Safety Commission) link: https://www.cpsc.gov/
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Archibaldo Silva
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023
LIC809 (FAS) - (06/04)
Page: 8 of 10
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: DUQUE GONZALEZ, LORNA
FACILITY NUMBER: 304314125
VISIT DATE: 06/21/2023
NARRATIVE
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LPA reviewed the following safe sleep best practices with the licensee:
  1. Always place infants 12 months and younger on their backs to sleep
  2. Use only a tight-fitting sheet on the crib or play yard mattress
  3. Do not hang any items from the crib or above the crib
  4. Keep all items including blankets, pillows, and stuffed dolls out of the crib or play yard
  5. Pacifiers may be used only if they do not have items attached to them and there is no recall
  6. Infants should not be swaddled or have any items covering them while sleeping
  7. The temperature of the room should be comfortable enough for a lightly clothed adult
  8. Complete Individual Sleeping Plan LIC9227 for infants 12 months and younger
  9. Conduct and document the 15-minute checks for all infants under 24 months
  10. CDSS Safe Sleep link: https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep
  11. A copy of “What does a safe environment looks like?” was provided and reviewed.

The facility was NOT in compliance. Violations of the California Code of Regulations, Title 22, Division 12 were observed, discussed, and cited at the time of the visit. The following violations of the California Code of Regulations, Title 22; Division 12, were observed and cited today: 102425(c), 102425(j)(1), 102425(b) and 102425(h) Infant Safe Sleep, 102370(d) Criminal Record Clearance, 102421(b) Child's Records, 102419(d)(1) Admission Procedures and Authorized Representatives Rights, 102417(m)(3) Operation of A Family Child Care Home,

LPA A. Silva informed licensee Lorna Duque that this licensing report dated 06/21/2023 documents 4 “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 Lorna Duque 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.
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Archibaldo Silva
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023
LIC809 (FAS) - (06/04)
Page: 9 of 10
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: DUQUE GONZALEZ, LORNA
FACILITY NUMBER: 304314125
VISIT DATE: 06/21/2023
NARRATIVE
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The LPA conducted an exit interview and reviewed the report with the licensee. The “Notice of Site Visit” was posted and the licensee is aware that it shall remain posted for 30 days. The Appeal Rights were explained. The licensee received a copy of the Appeal Rights (LIC 9058 01/16), 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.

To improve the quality and value of the inspection process, a survey will be sent to the email address provided. Please complete the survey to share your inspection experience. If you have any questions regarding the process or tools used during the inspection, email them to inspectionprocess@dss.ca.gov. For more information about the inspection, its tools, and methods visit www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

END
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Archibaldo Silva
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023
LIC809 (FAS) - (06/04)
Page: 10 of 10