<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 304314382
Report Date: 09/17/2025
Date Signed: 09/17/2025 01:39:10 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/11/2025 and conducted by Evaluator Olivia Meza
PUBLIC
COMPLAINT CONTROL NUMBER: 06-CC-20250811154417
FACILITY NAME:HOLLAND, JACQUELINEFACILITY NUMBER:
304314382
ADMINISTRATOR:HOLLAND, JACQUELINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 689-9971
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY:14CENSUS: 0DATE:
09/17/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jacqueline Holland TIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee did not maintain child’s immunization records at the facility
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 09/17/25 at 9:00AM, Licensing Program Analysts (LPAs) Olivia Meza and Dean Thompson conducted an unannounced visit to the facility to deliver findings for a complaint that was initiated on 08/20/2025. LPAs met with Licensee, Jacqueline Holland and explained the purpose of the visit. Licensee, Jacqueline Holland led LPAs on a tour of the facility and observed no children in care.

On 8/11/2025, the Orange County Regional Child Care Licensing Office received a complaint with allegation: Licensee did not maintain child’s immunization records at the facility
During the investigation, documents was requested, Licensee was interviewed, and authorized representatives.

continue to page two
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Martha Malane
LICENSING EVALUATOR NAME: Olivia Meza
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 06-CC-20250811154417
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: HOLLAND, JACQUELINE
FACILITY NUMBER: 304314382
VISIT DATE: 09/17/2025
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
26
27
28
29
30
31
32
page two
During record reviews, LPA requested immunization records for the total number of children currently enrolled. The licensee did not have documentation of immunization records on file for eight (8) out of (8) children. The licensee stated that they will request documentation of immunization for each child enrolled.

The Orange County Regional Child Care Licensing Office investigated the allegation: Licensee did not maintain child’s immunization records at the facility. Based on information gathered from LPA’s record review, the preponderance of evidence standard has been met; therefore, the allegation Licensee did not maintain child’s immunization records at the facility is found to be SUBSTANTIATED, California Code of Regulations Title 22, Division 12, Chapter 3 Article 6, Section CCR 102418 Immunizations (g) is being cited on the attached LIC 9099D.

end of report.
SUPERVISORS NAME: Martha Malane
LICENSING EVALUATOR NAME: Olivia Meza
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 06-CC-20250811154417
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: HOLLAND, JACQUELINE
FACILITY NUMBER: 304314382
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/26/2025
Section Cited
CCR
102418(g)
1
2
3
4
5
6
7
102418 Immunizations(g)The licensee shall document each child's immunizations… and shall maintain such documentation for as long as the child is enrolled.
This requirement is not met evidenced by:
1
2
3
4
5
6
7
Licensee states that they will Collect and submit proof to the department of immunization record for each child currently enrolled for a total of 14 children by the due date of 9/26/2025.
8
9
10
11
12
13
14
Based on record reviews, eight (8) out of eight (8) children enrolled had no record of immunizations in child file.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Martha Malane
LICENSING EVALUATOR NAME: Olivia Meza
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3