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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304370109
Report Date: 08/22/2023
Date Signed: 08/22/2023 12:58:30 PM

Document Has Been Signed on 08/22/2023 12:58 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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:JCC EARLY CHILDHOOD LEARNING CENTERFACILITY NUMBER:
304370109
ADMINISTRATOR:DALVA-HORNBACK, SHEILAFACILITY TYPE:
850
ADDRESS:1 FEDERATION WAY, STE. 200TELEPHONE:
(949) 435-3400
CITY:IRVINESTATE: CAZIP CODE:
92603
CAPACITY: 340TOTAL ENROLLED CHILDREN: 340CENSUS: 0DATE:
08/22/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Sheila Dalva-Hornback, Director TIME COMPLETED:
12:45 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
On 8/22/23, Licensing Program Analyst (LPA) Patricia Duron conducted a Case Management due to deficiencies investigated through interviews. LPAs met with Director, Sheila Dalva-Hornback. Census was taken and observed 0 preschool children and 1 staff including the Director.

A review of staff criminal clearance records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

During the investigation, LPA discovered on 4/14/2023, Child #1 (C1) received a scratch on the hand after waking up from nap. Staff #1 (S1) and S2 who were supervising C1 during the incident on 4/14/2023, did not know how C1 received the scratch. The facility is being cited for violating California Code of Regulations, Title 22, Division 12, Chapter 1 Section 101229(a)(1) Responsibility for Providing Care and Supervision. Please refer to attached 9099D for documentation of deficiencies.

An exit interview was completed. The report was reviewed and discussed. Appeal Rights were provided. The facility representative was provided a copy of their appeal rights and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Licensing office within 15 business days. Any proposed changes to the physical plant, including telephone number, shall be immediately reported to the Department.

The facility representative was informed that the “Notice of Site Visit” must be posted for 30 consecutive days. Failure to post will result in Civil Penalties of $100.00. The “Notice of Site Visit” must be posted on or adjacent to the door.

End of Report.

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Patricia Duron
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2023
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 2
Document Has Been Signed on 08/22/2023 12:58 PM - It Cannot Be Edited


Created By: Patricia Duron On 08/22/2023 at 11:28 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: JCC EARLY CHILDHOOD LEARNING CENTER
FACILITY NUMBER: 304370109

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/22/2023
Section Cited
CCR
101229

1
2
3
4
5
6
7
101229 Responsibility for Providing Care and Supervision (a)(1)No child(ren) shall be left without the supervision of a teacher at any time,except as
specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
1
2
3
4
5
6
7
 Director provided LPA with a written statement plan. Director will conduct training for staff on Supervision. Director will provide LPA with a list of staff names and their signatures due 9/1/23.
8
9
10
11
12
13
14
This requirement is not met as evidence by: Based on LPA’s interviews and observation,on 4/14/2023 C1 received a scratch on the hand after waking up from nap and the 2 staff members who was supervising C1 did not know how C1 received the scratch. This action poses an immediate risk to the safety of the child in care.

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.
SUPERVISOR'S NAME:Thuy Ho
LICENSING EVALUATOR NAME:Patricia Duron
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2