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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371252
Report Date: 03/06/2026
Date Signed: 03/06/2026 02:05:23 PM

Document Has Been Signed on 03/06/2026 02:05 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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:APPLE TREE PRESCHOOL & KINDERGARTENFACILITY NUMBER:
304371252
ADMINISTRATOR/
DIRECTOR:		GARDIWASAM, CHAMILAFACILITY TYPE:
850
ADDRESS:2211 WEST WOODLEY AVENUETELEPHONE:
(714) 772-1005
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 60TOTAL ENROLLED CHILDREN: 65CENSUS: 40DATE:
03/06/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:40 PM
MET WITH:Director, Chamila Gardiwasam TIME VISIT/
INSPECTION COMPLETED:
02:30 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
Licensing Program Analyst (LPA) A. Nunez conducted an unannounced case management incident inspection in response to a self-report Unusual Incident dated 1/16/2026. During today’s visit, LPA met with the Director, Chamila Gardiwasam. LPA took census and observed 40 children and 4 staff members. A review of the Facility Personnel Report Summary shows all facility staff or individuals who require caregiver background checks have received a criminal record clearance and a child abuse index clearance or an exemption clearance.

On 1/16/2026, a self-reported Unusual Incident Report (UIR) was filed with the Licensing Office. The facility reported on 1/16/2025 at approximately 10:30am, C1 fell from the climbing play structure and around 12:30pm C1’s parent picked up C1 and took C1 to the hospital. It was later determined that C1 had minimal posterior displacement on the right elbow.

During the investigation, LPA interviewed the director, Staff#1, Staff#2 and LPA attempted to interview C1, but C1 did not want to be interviewed by the LPA.



During staff interviews, Staff#1 (S1) stated the following S1 was standing by the infant classroom and Staff#2 (S2) was standing by the swings. S1 had scanned the playground and C1 was climbing on the climbing structure and when S1 turned back, S1 had seen C1 on the floor crying. S1 believes C1 must have fallen but did not see C1 fall. C1 was holding C1’s right arm and S2 took C1 inside the classroom. S1 stood outside with the rest of the children. S2 stated the following: S2 did not see C1 fall. S2 was by the swings of the play structure. C1 was crying during nap time and gave C1 an ice pack and called the parents to pick up C1. The director stated it was later determined that C1 had a minimal posterior displacement on the right elbow.

Page 1 of 2

NAME OF LICENSING PROGRAM MANAGER: Tina Nguyen
NAME OF LICENSING PROGRAM ANALYST: Aiddee Nunez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2026
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 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 4
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: APPLE TREE PRESCHOOL & KINDERGARTEN
FACILITY NUMBER: 304371252
VISIT DATE: 03/06/2026
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
26
27
28
29
30
31
32
Based on the staff interviews, the facility was not in compliance with California Code of Regulations, Title 22, Division 12 & Chapter 1, 101229(a)(1) Responsibility for Providing Care and Supervision is being cited; see LIC 809-D.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Director Chamila Gardiwasam.



Appeal Rights discussed. 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.

End of Report

Page 2 of 2

NAME OF LICENSING PROGRAM MANAGER: Tina Nguyen
NAME OF LICENSING PROGRAM ANALYST: Aiddee Nunez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2026
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 03/06/2026 02:05 PM - It Cannot Be Edited


Created By: Aiddee Nunez On 03/06/2026 at 01:00 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: APPLE TREE PRESCHOOL & KINDERGARTEN
FACILITY NUMBER: 304371252

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/20/2026
Section Cited
CCR
101229(a)(1)

1
2
3
4
5
6
7
101229 Responsibility for Providing Care and Supervision(a)The licensee shall provide care and supervision... to meet the children's needs.(1)No child(ren) shall be left without the supervision of a teacher at any time...
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Director stated since the incident she has provided supervision trainings to the staff members on 1/30/26. The director will provide the agenda of the training by the POC due date.
8
9
10
11
12
13
14
Based on staff interviews, the facility did not comply with the section cited above. Child #1 (C1) fell from the structure due to lack of supervision which poses a potential health, safety or personal rights risk to persons 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.
Tina Nguyen
NAME OF LICENSING PROGRAM MANAGER:
Aiddee Nunez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2026


LIC809 (FAS) - (06/04)
Page: 4 of 4