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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304370606
Report Date: 05/24/2023
Date Signed: 05/24/2023 02:20:58 PM

Document Has Been Signed on 05/24/2023 02:20 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:INDEPENDENCE CHRISTIAN PRESCHOOLFACILITY NUMBER:
304370606
ADMINISTRATOR:GASIMYAN, ADRINEFACILITY TYPE:
850
ADDRESS:4905 E LA PALMA AVENUETELEPHONE:
(714) 322-9246
CITY:ANAHEIMSTATE: CAZIP CODE:
92807
CAPACITY: 78TOTAL ENROLLED CHILDREN: 78CENSUS: 44DATE:
05/24/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:37 PM
MET WITH:Director Kim GauvainTIME COMPLETED:
02:30 PM
NARRATIVE
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On May 24 of 2023, Licensing Program Analysts (LPA) A. Silva conducted a Case Management due to deficiencies observed during today's visit. Director Gauvain assisted the LPA during the inspection. An on-site Facility Personnel Report Summary review indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Upon arrival LPA counted 30 preschool children and 5 staff in the Rock room (multipurpose room).

At approximately 11:30 am, LPA observed expired and/or missing mandated reporter certificates during staff records review. The LPA inquired about the mandated reporter certificates. The director stated that staff were in the process of completing them. At approximately 1:45 pm, based on records review, the LPA and the director determined that S1, S5, S6, S7 and S8 did not have a current mandated reporter certificate in file. This deficiency is cited in the attached 809D.

The LPA conducted an exit interview. Appeal Rights were discussed. The director received a copy of the appeal rights (LIC 9058). The director’s signature on this report acknowledges receipt of appeal rights and of this licensing report were received. All appeals must be in writing and received by the Regional Office within 15 business days. A Notice of site visit was provided and must remain posted for 30 days.

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Archibaldo Silva
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/24/2023 02:20 PM - It Cannot Be Edited


Created By: Archibaldo Silva On 05/24/2023 at 01:53 PM
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: INDEPENDENCE CHRISTIAN PRESCHOOL
FACILITY NUMBER: 304370606

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/26/2023
Section Cited
HSC
1596.8662(b)(1)

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Mandated Reporter Training: On or before March 30, 2018, a person who is a licensed child care provider, shall complete the mandated reporter training a), and shall complete renewal mandated reporter training every two years following the date on which the initial mandated reporter training. occurred
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The director stated that all staff will complete a mandated reporter by the due date. The director will send proof of correction to the LPA via email no later than 6/26/2023.
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this requirement was not met as evidenced by:
Based on records review, the licensee did not meet with the above requirement in 5 out 5 staff, which poses a risk to the health and safety of children in care.
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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: 05/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2023


LIC809 (FAS) - (06/04)
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