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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304370734
Report Date: 12/19/2023
Date Signed: 12/19/2023 02:26:11 PM

Document Has Been Signed on 12/19/2023 02:26 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 COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:FUN 4 KIDS PRESCHOOLFACILITY NUMBER:
304370734
ADMINISTRATOR:SILVA, DAWNFACILITY TYPE:
850
ADDRESS:23721 LA PALMA AVENUETELEPHONE:
(714) 694-0901
CITY:YORBA LINDASTATE: CAZIP CODE:
92887
CAPACITY: 76TOTAL ENROLLED CHILDREN: 76CENSUS: 30DATE:
12/19/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:41 PM
MET WITH:Director Melissa WojickTIME COMPLETED:
02:50 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 12/19/23 Licensing Program Analyst (LPA) Anna Chan created a case management deficiency report. LPA met with Director Melissa Wojick informed the Director of the purpose of the visit. During today's visit, a tour of the facility was conducted. The overall census observed was 30 preschool children and 4 staff.

During a complaint investigation on 11/09/23, it was discovered that on 10/24/23, a child in care needed medical attention and emergency medical services came. There are no records of the facility contacting Community Care Licensing Department reporting the incident.

LPA Chan reviewed the Unusual Incident (LIC 624) and Reporting Requirements with the director.

Based on record reviewed the following deficiency was discussed and cited. The facility was not in compliance with the California Code of Regulations, Title 22, Division 12, Section 102416.2 (d)(1)(B) Reporting Requirements. Please refer to 809D for details of deficiency.

Exit interview was conducted. Notice of Site Visit was posted during the visit. Director, Melissa Wojick 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. Appeal rights provided and explained. The Licensee was provided a copy of their appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. First level appeals should be sent to the regional manager to the address listed above.

End of Report

SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Anna Francesca Chan
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2023
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 12/19/2023 02:26 PM - It Cannot Be Edited


Created By: Anna Francesca Chan On 12/19/2023 at 01:24 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: FUN 4 KIDS PRESCHOOL
FACILITY NUMBER: 304370734

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/19/2024
Section Cited
CCR
101212(d)(1)(B)

1
2
3
4
5
6
7
Reportin Requirements
(d) Upon the occurrence, during the operation of the child care center of any of the event...
(1) Events reported shall include the following: (B) Any injury to any child that requires medical treatment.
1
2
3
4
5
6
7
Director stated they will report any future unsual incidents to licensing office. Director will send email to LPA with statement by POC due date.
8
9
10
11
12
13
14
This evidence is not met by:
Based on staff interview, Facility did not call licensing office within 24 hours of occurance and did not send LIC624 Unusual Incident.
This is a potential risk to the personal rights to the children 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:Judy Hanson
LICENSING EVALUATOR NAME:Anna Francesca Chan
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2023


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