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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371213
Report Date: 11/10/2022
Date Signed: 11/10/2022 12:05:20 PM

Document Has Been Signed on 11/10/2022 12:05 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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:LEPORT-IRVINE SPECTRUM-SOUTH CAMPUSFACILITY NUMBER:
304371213
ADMINISTRATOR:RIVAS, ANAFACILITY TYPE:
850
ADDRESS:1 TECHNOLOGY DRIVE, BLDG HTELEPHONE:
(949) 525-9922
CITY:IRVINESTATE: CAZIP CODE:
92618
CAPACITY: 156TOTAL ENROLLED CHILDREN: 113CENSUS: 98DATE:
11/10/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Ana Rivas, director TIME COMPLETED:
12:15 PM
NARRATIVE
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On 11/10/2022 Licensing Program Analyst (LPA), Stella Gutierrez made an unannounced facility inspection for a case management. LPA, Gutierrez was met by the director who was explained the reason for todays visit.

On 11/02/2022 there was a self reported incident by the director that a child sustained an injury while in care on 11/01/2022. It was reported that the child was reaching for a paper towel with right hand from the paper towel dispenser that is sensored in the toddler classroom #5. As the child reached for the towel with his/her right hand the child than placed their left hand ran into the blunt serrated edge where the child’s nail got stuck and making the nail lift almost completely.



LPA observed the paper towel dispensers to have sharp edges inside where the dispenser paper towel is distributed. LPA, Gutierrez provided a copy of dispenser manual where it states that the bottom of the dispenser installation should be approximately 48 inches off the ground. LPA measured the bottom of the dispenser to be 32 inches off the ground in classroom #5.

LPA interviewed 03 staff during today's visit. Staff #1 stated that on 11/01/20022 the child in question was washing his/hands when the child went to retrieve a paper towel from the dispenser. The child then looked over to staff #1 as staff #1 was assisting another child. Staff #1 stated the child put his/her right hand up in to the dispenser to retrieve a a paper towel which resulted in the child sustaining an injury. Staff #2 stated that he/she heard the child crying and attended the child to find that the child right pointing finger nail was bleeding and the nail had lifted. Staff #2 applied aide and the director called he parent immediately.


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SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Stella Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2022
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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: LEPORT-IRVINE SPECTRUM-SOUTH CAMPUS
FACILITY NUMBER: 304371213
VISIT DATE: 11/10/2022
NARRATIVE
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Based on LPA’s observation and interviews conducted the child sustained in injury in care due to the child not being provided assistance and the installation of the paper towel dispenser not being installed according to the manual from the distributor. The following violation was observed is being cited in accordance with California Code of Regulations, Title 22, Division 12, Chapter 1, Section 101223 (a) (2) , is being cited on the attached LIC 809D.

Exit interview conducted and report was reviewed with the director, Ana Rivas 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 given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

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SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Stella Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/10/2022 12:05 PM - It Cannot Be Edited


Created By: Stella Gutierrez On 11/10/2022 at 11:47 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: LEPORT-IRVINE SPECTRUM-SOUTH CAMPUS
FACILITY NUMBER: 304371213

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/21/2022
Section Cited
CCR
101223(a)(2)

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101223 Personal Rights
(a) The licensee shall ensure that each child is accorded the following personal rights:
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
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The director understand that the dispenser must be removed and replaced or installed according to the manufacturers manual provided. The director will provide this plan of correction by the specified date of 11/21/2022

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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:Stella Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2022


LIC809 (FAS) - (06/04)
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