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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 304370730
Report Date: 11/09/2023
Date Signed: 11/09/2023 09:03:17 AM

Substantiated


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
11/06/2023 and conducted by Evaluator Dean Thompson
PUBLIC
COMPLAINT CONTROL NUMBER: 06-CC-20231106111705
FACILITY NAME:ACADEMY ON THE HILLSFACILITY NUMBER:
304370730
ADMINISTRATOR:LUNN, MONICAFACILITY TYPE:
850
ADDRESS:10 MAREBLUTELEPHONE:
(949) 360-7022
CITY:ALISO VIEJOSTATE: CAZIP CODE:
92656
CAPACITY:102CENSUS: 36DATE:
11/09/2023
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Monica LunnTIME COMPLETED:
09:25 AM
ALLEGATION(S):
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Staff do not ensure that sign in/out sheets are maintained accurately.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Thompson conducted an unannounced complaint investigation. This is a continuation of the investigation initiated on 11/7/2023. LPA met with Director Monica Lunn. Census was taken in each individual classroom. LPA observed 12 preschool age children with two staff inside the Two's classroom, 6 preschool age children with one staff inside the Jr. Pre- k classroom, 13 preschool age children with two staff inside the Pre-K 1 classroom, and 5 preschool age children with 1 staff inside the Pre-K 2 classroom.

A review of the Facility Personnel Report Summary on this date indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. During today’s inspection the facility was operating within its licensed capacity and within compliance with staffing ratios. On 11/6/2023 the facility was operating within its licensed capacity and within compliance with staffing ratios.

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Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Dean Thompson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023
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 4
Control Number 06-CC-20231106111705
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: ACADEMY ON THE HILLS
FACILITY NUMBER: 304370730
VISIT DATE: 11/09/2023
NARRATIVE
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The Orange County Child Care Office received a complaint on 11/6/2023 alleging staff do not ensure that sign in/out sheets are maintained accurately.



During the investigation on 11/7/2023, LPA’s Thompson and Navar reviewed Academy On The Hills sign in/out sheets for November 7, 2023. LPA’s also reviewed sign in/out sheets from 11/1/2023 through 11/6/2023. On 11/7/2023, LPA's observed 20 preschool age children with two staff inside the Two's classroom but only 18 preschool age children were signed in for the day. Out of the 18 children signed in, one child was missing the time in. Per licensing regulations, the person who signs the child in/out shall use his/her full legal signature and shall record the time of day. Also, the person who brings the child to, and removes the child from, the center shall sign the child in/out.

On 11/7/2023 LPA’s observed 24 preschool age children with one staff inside the Pre-K 1 classroom. According to the Sign in/out sheets, only 21 children were signed in.

On 11/7/2023 LPA’s observed 30 preschool age children with 4 staff inside the Pre-K 2 classroom. After reviewing the sign in sheets, it was determined only 27 children were signed in.

On 11/7/2023, LPA Thompson conducted parent interviews. LPA contacted 11 parents via phone call. Out of 11 parents, five (5) parents were able to be interviewed. The parents interviewed did not divulge any information regarding the allegation.

On 11/9/2023 LPA’s observed 12 preschool age children inside the Two's classroom. According to the Sign in/out sheets, only 10 children were signed in.

On 11/9/2023 LPA’s observed 13 preschool age children inside the Pre-K 1 classroom. According to the Sign in/out sheets, only 12 children were signed in.

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SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Dean Thompson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 06-CC-20231106111705
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: ACADEMY ON THE HILLS
FACILITY NUMBER: 304370730
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/16/2023
Section Cited
CCR
101229.1(b)
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CCR 101229.1 Sign In and Sign Out (b)The person who brings the child to, and removes the child from, the center shall sign the child in/out.

This requirement is not met evidenced by:
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Directed stated she sent out an email to all parents reminding them the imprtance of signing in and sign out the child/children. Plan of correction due by 11/16/2023 to LPA Dean at Dean.thompson@dss.ca.gov or the regional office.
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Based on sign in/ sign out sheets reviewed on 11/7/2023 and 11/9/2023 showing 36 children present but only 33 children were signed in poses/posed a potential health, safety or personal rights risk to persons 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.
SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Dean Thompson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 06-CC-20231106111705
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: ACADEMY ON THE HILLS
FACILITY NUMBER: 304370730
VISIT DATE: 11/09/2023
NARRATIVE
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Based on LPA’s observation and documentation reviewed, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division & Chapter 12, is being cited on the attached LIC 9099 D for the deficiency sections 101229.1(b) Sign In and Sign Out.

Exit interview conducted and report was reviewed with Director Monica Lunn.



A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Appeal Rights discussed. The Director 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.
SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Dean Thompson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4