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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371253
Report Date: 09/20/2024
Date Signed: 09/20/2024 04:15:22 PM


Document Has Been Signed on 09/20/2024 04:15 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 CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868



FACILITY NAME:APPLE TREE PRESCHOOL & KINDERGARTENFACILITY NUMBER:
304371253
ADMINISTRATOR:PERANCULLO, MARBENFACILITY TYPE:
830
ADDRESS:2211 WEST WOODLEY AVENUETELEPHONE:
7147721005
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY:30CENSUS: 24DATE:
09/20/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:06 PM
MET WITH:Chamila Gardwasan (Director)TIME COMPLETED:
04:15 PM
NARRATIVE
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On 9/20/2024, Licensing Program Analysts (LPAs) A. Silva conducted a Case Management – Deficiencies inspection due to observed deficiencies during today's inspection. Director Chamila Gardiwasam assisted the LPA during the visit. An on-site Facility Personnel Report Summary review indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions, except for staff Lina Watban. The LPA observed Lina providing care and supervision to infants in care in the infant room and in the infant playground.

In an interview, Lina stated that her start date was August 2024. The Director Gardiwasam and manager Lagarza both corroborated that Lina’s start date was August 9, 2024 and that Lina’s title was Infant Room Head Teacher.

Based on records review and interviews conducted, the facility is being cited in accordance with California Code of Regulations, Title 22, Division 12, Section 101170(e) Criminal Background Clearance for one uncleared staff who was observed providing care and supervision to infants in the infant room one and the infant playground.

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 provided and must remain posted for 30 days. An exit interview was conducted, and the report was reviewed with Director Gardiwasam.
SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Archibaldo SilvaTELEPHONE: (510) 504-4954
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024
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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Document Has Been Signed on 09/20/2024 04:15 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: APPLE TREE PRESCHOOL & KINDERGARTEN
FACILITY NUMBER: 304371253

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/20/2024
Section Cited
CCR
101170(e)

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101170(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility…
The licensee did not meet this requirement as evidenced by:
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Staff will exit the facility and obtain a clearance or transfer any existing clearance to the facility. The staff will not return until cleared and associated to the facility. The director will send a request for clearance or clearance trasnsfer within 24 hours.
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Based on records reviewed and interviews conducted, the regulation was not met. Lina Watban did not have clearance and was observed providing care and supervision, which poses an immediate risk to the health and safety risk to children 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.
SUPERVISOR'S NAME: Patricia MaganaTELEPHONE: (714) 703-2821
LICENSING EVALUATOR NAME: Archibaldo SilvaTELEPHONE: (510) 504-4954
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024
LIC809 (FAS) - (06/04)
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