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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304370877
Report Date: 06/05/2024
Date Signed: 06/05/2024 02:07:36 PM

Document Has Been Signed on 06/05/2024 02:07 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:CALVARY BAPTIST CHURCH-IKIDS PRESCHOOLFACILITY NUMBER:
304370877
ADMINISTRATOR/
DIRECTOR:		RENEE DURANFACILITY TYPE:
830
ADDRESS:612 NORTH ROSE DRIVETELEPHONE:
(714) 961-5437
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 15DATE:
06/05/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:10 AM
MET WITH:Cindy Gough, Assistant Director TIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA), Sarah Garcia conducted an onsite inspection for the purpose of an Annual Random. LPA and assistant director, Cindy Gough conducted a walk-through of the facility inside and outside and the floor and yard plan were verified. Census was taken in individual classrooms. The overall census observed was 15 infants and 4 staff. At 10:00am, LPA met with director, Renee Duran. During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staffing ratios. Facility hours are 7:00a.m.- 6:00p.m., Monday through Friday. 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 the inspection of the indoor activity space, items which could pose a danger to children (detergents, cleaning compounds, and medications) were observed to be stored out of the reach of children. Poisons/Hazardous Items are not kept on the premises. Food and milk are provided by parents and properly labeled and stored in the refrigerator in infant's container. Floors, equipment, and furniture were clean and were observed to be in good repair and free of sharp edges. LPA observed a changing table with a sink next to it. LPA did not observe an infant sleep observation log (24 months and under). LPA discussed safe sleep regulations with assistant director. LPA issued a Type B citation. LPA provided a sample observation log to director. Infants nap in cribs, and bedding is stored individually and is taken home daily to be washed by parents or facility washes bedding at end of day. LPA observed the infant napping area separated via plexiglass. Per assistant director, the facility has not conducted an emergency drill within the past six months. LPA did not observe a emergency drill log. LPA issued a Type B citation. The facility has a working carbon monoxide detector and fire extinguisher 2A10BC. Facility met all posting requirement. The California Child Passenger Safety Law was posted by the entrance of the facility.
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SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Sarah Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 06/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: CALVARY BAPTIST CHURCH-IKIDS PRESCHOOL
FACILITY NUMBER: 304370877
VISIT DATE: 06/05/2024
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Staff files were reviewed for staff present during the facility inspection on this date, 4 out of 4 staff files were reviewed. Health screening and immunizations as required were reviewed. Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles for (licensee and assistant) were reviewed and within compliance. Beginning March 31, 2018, H&S Code 1596.8662 requires all directors and employees to complete mandated reporting training, and to renew the training every two years. At least one staff member present possesses current EMSA approved Pediatric CPR/First Aid certifications, which expires 1/2025.

Children's records were reviewed, and there was a separate, complete and current record for each child. A random sample of (4) of children's files were reviewed for documentation of the child’s name, address, and telephone number of the child’s authorized representative and of relatives or others that can assume responsibility for the child if the authorized representative cannot be reached when necessary and a medical assessment. LPA observed (2) files from 0-12 months. LPA did not observed LIC 9227 Individual Infant Sleeping Plan in children’s files. LPA will issue Type B citation. In the areas reviewed the children’s files were found to be in full compliance. Sign in/out procedure was reviewed for compliance. The person who signs the child in and out uses their full legal signature and records the time of the day. LPA did not observe Needs and Services Plan for the infants. LPA discussed needs and services plan with director and assistant director. LPA issued a Type B citation.

LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm



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SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Sarah Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2024
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: CALVARY BAPTIST CHURCH-IKIDS PRESCHOOL
FACILITY NUMBER: 304370877
VISIT DATE: 06/05/2024
NARRATIVE
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The outdoor activity space was inspected for compliance. The playground was enclosed by a fence at least four feet in height. The surface of the outdoor activity space was well maintained and free of hazards. LPA observed cushioning material, wood chips around the climbing equipment, slides and other similar equipment appeared to be enough to absorbs falls. The outdoor equipment and toys were in good repair and free of sharp edges. There are no bodies of water present at the facility. The facility grounds were safe, sanitary and in good repair. LPA advised assistant director to sand down the wooden boat and bridge to prevent splintering. LPA advised assistant director to rake the wood chips to ensure an even surface. LPA took photographs.

The director was informed that Licensing Quarterly Updates are available at www.ccld.ca.gov and may request to be added to an email list to receive a Quarterly Update. The Child Care Advocate at childcareadvocatesprogram@dss.ca.gov or at www.ccld.ca.gov LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian

Information on the additional nutrition training, immunization requirements for children, and Health Schools Act (http://www.cdpr.ca.gov/docs/pestmgt/schoolipm.htm) were provided. The director was informed, and website given, about the California Child Care Disaster Plan has been posted to the UCSF California Childcare Health Program website: cchp.ucsf.edu/content/disaster-preparedness Also provided was information about the E-Learning Modules available at https://ccld.childcarevideos.org A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the facility representative.

A copy of the 2016 “A Child Care Providers Guild to Safe Sleep” was provided to the director.
English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf
AAP: https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx
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SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Sarah Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2024
LIC809 (FAS) - (06/04)
Page: 3 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: CALVARY BAPTIST CHURCH-IKIDS PRESCHOOL
FACILITY NUMBER: 304370877
VISIT DATE: 06/05/2024
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NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative
Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials
· Always place infants on their backs for sleeping
· Use only a tight-fitting sheet on the crib or play yard mattress
· Do not hang any items from the crib or above the crib
· Keep all items, including blankets, out of the crib or play yard
· Pacifiers may be used as long as they do not have items attached to them
· Infants should not be swaddled or have any items covering them while sleeping
· The temperature of the room should be comfortable enough for an adult to wear a t-shirt and not be too hot or too cold

Based on California Code of Regulations, Title 22, Division 12, Chapter 3, (4) deficiencies will be cited today.

An Inspection and exit interview was completed with director and assistant director. The report was reviewed and discussed. Appeal Rights and deficiencies 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.

The facility representative was informed that the “Notice of Site Visit” must be posted for 30 consecutive days. The “Notice of Site Visit” must be posted on or adjacent to the door. Failure to post will result in Civil Penalties of $100.00.




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SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Sarah Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/05/2024 02:07 PM - It Cannot Be Edited


Created By: Sarah Garcia On 06/05/2024 at 11:59 AM
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: CALVARY BAPTIST CHURCH-IKIDS PRESCHOOL
FACILITY NUMBER: 304370877

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101174(d)(2)
Disaster and Mass Casualty Plan
(d) Disaster drills shall be conducted at least every six months. (2) The drills shall be documented. This documentation shall be kept in the child care center for at least one year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review, the licensee did not comply with the section cited above LPA did not observe a documentation of disaster drill log which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/10/2024
Plan of Correction
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Director will conduct and document diaster drill on 6/7/2024. LPA provided a sample log to director. Director will send drill documentation to LPA email at sarah.garcia@dss.ca.gov by 5pm on 6/10/2024.
Type B
Section Cited
CCR
101429(a)(2)(B)
Responsibility for Providing Care and Supervision for Infants
(B) Staff shall physically check on sleeping infant(s) every 15 minutes and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in facility did not provide documentation on15 minute check up which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/05/2024
Plan of Correction
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LPA discussed safe sleep regulations with director. LPA observed director provide infant staff copies of observation logs to begin implementating 6/5/24. LPA observed observation logs being completed by staff.
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:Sarah Garcia
LICENSING EVALUATOR SIGNATURE:
DATE: 06/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2024


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 06/05/2024 02:07 PM - It Cannot Be Edited


Created By: Sarah Garcia On 06/05/2024 at 11:59 AM
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: CALVARY BAPTIST CHURCH-IKIDS PRESCHOOL
FACILITY NUMBER: 304370877

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101429(a)(2)(B)(3)(a)
Responsibility for Providing Care and Supervision for Infants
(B) Staff shall physically check on sleeping infant(s) every 15 minutes and document the following: (3) Infants up to 12 months of age who are sleeping in a position other than on their back. (a) 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 4 out of 4 infant's files did not have current LIC 9227 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/05/2024
Plan of Correction
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LPA discussed safe sleep regulations with director and assistant director. Director emailed and provided LIC 9227 to infants parents on 6/5/24 and LPA observed a completed LIC 9227.
Type B
Section Cited
CCR
101419.2(a)
Infant Needs and Services Plan
(a) Prior to the infant's first day at the center, the infant care center director or assistant director shall complete a needs and services plan for the infant.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 4 out of 4 infant's files did not have current needs and services plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/10/2024
Plan of Correction
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LPA discussed needs and services plan with licensee. Director will create a needs and services and provide to parents. Director will send needs and services plan to LPA via email sarah.garcia@dss.ca.gov by 5pm on 6/10/2024.
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:Sarah Garcia
LICENSING EVALUATOR SIGNATURE:
DATE: 06/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2024


LIC809 (FAS) - (06/04)
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