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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304370606
Report Date: 07/20/2023
Date Signed: 07/20/2023 01:02:47 PM

Document Has Been Signed on 07/20/2023 01:02 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: 13DATE:
07/20/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:29 PM
MET WITH:Yasbel OrtunoTIME COMPLETED:
01:30 PM
NARRATIVE
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On 7/20/23, Licensing Program Analyst (LPA) A. Silva conducted a Case Management – Deficiencies due to deficiencies observed during a visit. 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. Census was 13 at the time of visit. The facility was operating within ratios and capacity.

At approximately 11:00 a.m., LPAs requested documentation of Director Kimberly Guavain’s actual hours worked for a specific date. Assistant Principal Ms. Compos stated the director does not have a sing in/out requirement because she is on salary and there is no document showing what hours Director Kimberly Guavain worked. Teacher Yasbel Ortuno provided a copy of the personnel report showing Director Kimberly Guavain’s schedule is M-F 8am to 5pm dated 6/19/2023. No other documentations of the director’s actual hours worked was available on 7/20/23.

Based on interviews conducted with the Assistant Principal Erin Compos and Teacher Yasbel Ortuno, the facility is being cited in accordance with California Code of Regulations, Title 22, Division 12, for the following section: 101217 Personnel Records.

Appeal Rights were discussed. The facility representative was provided 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. A notice of site visit was provided and must remain posted for 30 days. Exit interview conducted and report was reviewed with Yasbel Ortuno.

End.

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Archibaldo Silva
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2023
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 07/20/2023 01:02 PM - It Cannot Be Edited


Created By: Archibaldo Silva On 07/20/2023 at 12:48 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: 07/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/21/2023
Section Cited
CCR
101217

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101217 Personnel Records (e) In all cases, personnel records shall document the hours actually worked.

The licensee did not comply with the regulation above as evidenced by:
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Director Kimberly Guavain will document actual hours work.
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Based on interviews conducted with the Assistant Principal Erin Compos and Teacher Yasbel Ortuno, the licensee did not comply with the above regulation in one out of one staff, which poses a risk to the health, safety, or personal rights or 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: 07/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2023


LIC809 (FAS) - (06/04)
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