304370257-6-18-2025-06-CC-THOO-DJ6V6P-20250701160952

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 304370257
Report Date: 06/18/2025
Date Signed: 06/18/2025 03:51:06 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 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
05/23/2025 and conducted by Evaluator Mahnaz Malek

PUBLIC

COMPLAINT CONTROL NUMBER: 06-CC-20250523082501

FACILITY NAME:	TUTOR TIME CHILD CARE/LEARNING CENTER		FACILITY NUMBER:	304370257
ADMINISTRATOR:	MARY JOY HILSABECK		FACILITY TYPE:	830
ADDRESS:	24291 AVILA ROAD		TELEPHONE:	(949) 831-8887
CITY:	LAGUNA NIGUEL	STATE: CA	ZIP CODE:	92677
CAPACITY:	40	CENSUS: 18	DATE:	06/18/2025
		UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Director		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Infant room is out of ratio
Staff covered an infant’s mouth with their hand to stop from crying
Infant room is not sanitized
staff falsifying child was fed on sprout app
Infant Sleep Plan not given to parent /in child file
Aide was left alone supervising infants

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mahnaz (Nancy) Malek conducted a follow up investigation regarding the above allegations. This is a follow-up for the visit conducted on 5/28/2025. LPA met with director, Mary Joy Hilsabeck. Census was taken. There was a total of 18 infants and toddlers with 5 staff in two different rooms. There were 5 infants with 2 staff in infant room 1, and there were 13 toddlers with 4 staff in Toddler Room 2. Infant Room 2 and Toddler Room 1 were not in use.

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

Continued on page 2

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025

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 6

Control Number 06-CC-20250523082501

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: TUTOR TIME CHILD CARE/LEARNING CENTER	FACILITY NUMBER: 304370257
	VISIT DATE: 06/18/2025

NARRATIVE

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On 05/23/2025, the Orange County Child Care Office received a complaint alleging 1) Infant room is out of ratio, 2) Staff covered an infant’s mouth with their hand to stop from crying, 3) Infant room is not sanitized, 4) staff falsifying child was fed on sprout app, 5) Infant Sleep Plan not given to parent /in child file, 6) Aide was left alone supervising infants.

Reporting Party (RP) reported the infant room is always out of ratio. On 5/23/25 there were five infants with one staff and the 6th child arrived at 8:00 am. Reporting party stated two days ago, 9-year-old child, brought it up to reporting party’s attention that 9-year-old child saw a staff member covering an infant’s mouth to stop them from crying. Also reported the floors are dusty and dirty, they don’t seem to clean the rooms. R/P further stated it was observed through live camera footage that Child # 1 (C1) was sleeping but received a notification that C1 was fed. R/P further reported it was observed C1 sleeping on belly with face to the bed and crying. When asked to move C1, it was said that they need a paper to be signed. No form was offered to be filled out.R/P stated the staff in the infant rooms are aides and they are left alone with children.

During the course of investigation, LPA interviewed seven (7) staff who work in the infant room. Staff # 1 (S1), (S2), (S3), (S4), (S5), (S6), and (S7). Nine-year-old child was also interviewed. LPA gathered additional documentation regarding the above allegations.

Regarding the allegation of Infant room is out of ratio,
Staff did not confirm being out of ratio. The staff had knowledge of the teacher child ratio which is 1:4. They stated they would call the office for extra staff as soon as they see additional child arrives which makes them out of ratio. LPA reviewed the sign in/out sheet, and name to face for the Infant Room referred date on the complaint report. (5/23/2025). LPA observed there were enough staff to cover the number of children. However, the records shows the increment of every hour of number of children and staff on Name to Face Transition Record. Staff stated sometimes the staff are not in the zone of the camera footage and seems like lack of staff in the room.
Regarding the allegation of staff covered an infant’s mouth with their hand to stop from crying.
All staff denied doing it or witnessing such incident. S1 stated it was brought up to S1 that 9-year-old child observed the incident. The names of the staff were not confirmed. However, the staff who were in the room
Continued on page 3

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 06-CC-20250523082501

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: TUTOR TIME CHILD CARE/LEARNING CENTER	FACILITY NUMBER: 304370257
	VISIT DATE: 06/18/2025

NARRATIVE

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on that moment did not confirm that this incident occurred. S5 stated S4 was holding a baby that was crying and S5 was in the room and did not observe such incident. LPA interviewed the 9-year-old child who had discrepancies in their responses. C2 referred to child C1 while S5 did not confirm the alleged incident was related to C1. Staff stated they pick up the infants when cry and they give them love and care to comfort them.

Regarding the allegation of Infant room is not sanitized
Staff stated they have a schedule to work in their room when they are not working with children. They stated that they sanitize the toys and equipment in the room, they vacuum, they mop, and dust. Staff stated the
scheduling is from Monday to Friday with specific responsibility for each staff. LPA was submitted a schedule of the items need to be done by each staff. Also, LPA was submitted a copy of verification of shampooing the carpet and wax flooring. The strip and wax vinyl including high speed burnishing were done on 4/26/2025, and carpet cleaning was completed on 5/2/2025. According to the documents received, these were done by professionals.

Regarding the allegation of staff falsifying child was fed on sprout app
S1 stated there are 3 entities that staff log every day and those are feeding time, diaper time, and napping time. Few staff stated they log the time right away after a child is fed or changed or napped. Few staff stated they might be sometimes delay in time. They might feed a child and change the child and put the child to nap and forget to log them right away. However, they log it with a delay. Therefore, when they log it on the App, it records the current time for all the activities. Staff stated it might have happened few times, but staff remember to change the time and record the exact time for each activity on the App. Staff stated this does not mean they are falsifying the time of the feeding, diaper changing, or napping. Staff stated they remember when using App, they enter the actual time manually to prevent recording the current time.

Regarding the allegation of Infant Sleep Plan not given to parent /in child file
S1 stated if a baby rolls over with signed paper, we let the child roll on their own. C1 was requested to roll over while sleeping, they were informed doctor’s note was needed. S1 stated the form was given to C1’s representative and had been signed that the child could roll over with C1’s representative’s signature.
Continued on page 4

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 06-CC-20250523082501

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: TUTOR TIME CHILD CARE/LEARNING CENTER	FACILITY NUMBER: 304370257
	VISIT DATE: 06/18/2025

NARRATIVE

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Staff # 2 (S1) stated they roll C1 on the back whenever C1 is rolling.
S3 stated they put the babies on their back. If they roll over, they do it themselves.
S4 stated I lay the baby on the back. If they roll over on themselves, we let them do on their own. If we don't know, we roll them on the back if not sleeping. We know which child rolls and which child does not.
S5 stated they put the babies on their back. If they roll over themselves, they don't turn them.
S6 stated they put babies to sleep on their back. It depends on the child. C1 could roll from back to tommy and not from tommy to back. C1 was not observed to roll over.
S7 stated It depends on the child's status. If they can roll over, they do it on their own.

Regarding the Aide was left alone supervising infants
Staff did not confirm that the aides supervise children while being left alone. The aides who work in the infant room confirmed that they always work with a teacher. LPA reviewed the qualification for staff in the infant room. When interviewed with staff, they stated the arrangement with the name of the staff in the room. LPA found that the combination of teacher and aid are arranged supervising children and not aide alone. Staff stated they know who a qualified teacher is and who is an aid. The aids understand that they cannot be left alone with children without a presence of a teacher. They said aides are not alone with children. One teacher and two aides might have been working together when they have a maximum of 12 infants but not two aides together.

Based on the interviews with seven staff, nine (9) year old child (C2), contacting ten random parents of whom one responded with no concerns regarding the allegations, and reviewing relevant documents, such as records of staffs' times and sign in/out sheet for children, and internal Name to Face Transition Record, there are not enough evidence, or witness to support the above allegations. This agency has investigated the complaint alleging 1) Infant room is out of ratio, 2) Staff covered an infant’s mouth with their hand to stop from crying, 3) Infant room is not sanitized, 4) staff falsifying child was fed on sprout app, 5) Infant Sleep Plan not given to parent /in child file, 6) Aide was left alone supervising infants, “although the allegations may have happened or are valid, there is not a preponderance of evidence to prove, the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED.
Continued on page 5

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 06-CC-20250523082501

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: TUTOR TIME CHILD CARE/LEARNING CENTER	FACILITY NUMBER: 304370257
	VISIT DATE: 06/18/2025

NARRATIVE

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During the course of investigation, interviewing staff, and reviewing documents, LPA found that the Individual Infant Sleeping Plan was not filled out completely in Section C for C1 which describes the status of the napping position. Therefore, California Code Title 22 Regulations Section 101429.3(a) was cited on next page (LIC 9099D).

During the course of investigation, interviewing staff, and reviewing documents, LPA found that the facility did not report to Licensing Office as it was required to when it was brought up to the staff's attention that an alleged incident of staff covered an infant’s mouth with their hand to stop from crying. Therefore, California Code of Title 22 Regulation under Section 101222 was cited on next page (LIC 9099D)

The director, Mary Joy Hilsabeck, was provided with a copy of their appeal rights (LIC 9058) 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. The exit interview was conducted with director, Mary Joy Hilsabeck.

Notice of Site Visit was posted. The notice of site visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100.
Exit interview was conducted with director, Maryjoy Hilsabeck.

End of the report.

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 06-CC-20250523082501

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: TUTOR TIME CHILD CARE/LEARNING CENTER	FACILITY NUMBER: 304370257
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/18/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/20/2025 Section Cited CCR 102429.3(a)	1 2 3 4 5 6 7	Infants up to 12 months of age who are sleeping in a position other than on their back if the infant’s individual infant sleeping plan LIC 9227 (3/20) does not have Section C completed, staff shall return the infant to their back for sleeping.	1 2 3 4 5 6 7	The director agreed to review the LIC 9227 with staff regarding the position status of infants under 12 months old to have a clear understanding of the form and send a statement acknowledging the section with staff to LPA by the due date of
	8 9 10 11 12 13 14	This requirement was not met as evidenced by reviewing C1’s LIC 9227 which Section C was not filled out completely regarding C1's sleeping position. This is a potential hazard to the health and safety of children in care.	8 9 10 11 12 13 14
Type B 06/20/2025 Section Cited CCR 102416.2(d)	1 2 3 4 5 6 7	Upon the occurrence, during the operation of the childcare center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containg the information	1 2 3 4 5 6 7	The director agreed to send a statement to LPA’s email address indication they are aware of the reporting requirements including reporting any alleged incidents that threatens the physical or emotional health or safety of
	8 9 10 11 12 13 14	specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event. The above requirement was not met as evidenced by during the course of investigation an alleged incident was not reported to licensing office as it was required to. This is a potential hazard to the health and safety of children in care.	8 9 10 11 12 13 14	any child.

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: Thuy Ho
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025

LIC9099 (FAS) - (06/04)

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