304371468-2-14-2023-06-CC-PRIS-CKLUKA-20221027153849

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304371468
Report Date: 10/27/2022
Date Signed: 02/14/2023 09:53:49 AM

Document Has Been Signed on 02/14/2023 09:53 AM - 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:	SERENDIB ANAHEIM LLC, DBA LITTLE MINDS LEARNING AC		FACILITY NUMBER:	304371468
ADMINISTRATOR:	LUCERO RUBI		FACILITY TYPE:	830
ADDRESS:	1845 WEST LA PALMA		TELEPHONE:	(714) 215-4293
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92801
CAPACITY: 20	TOTAL ENROLLED CHILDREN: 11	CENSUS: 6	DATE:	10/27/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	08:34 AM
MET WITH:	Lucero Rubi, Director		TIME COMPLETED:	03:45 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	This is an amended report that supersedes a report created on 10/27/22. The Deficiency Type was corrected from B to an A for Section 101429(a) Responsibility for Providing Care and Supervision for Infants. The remainder of the report remains the same. Licensing Program Analyst (LPA) P. Rivas conducted a case management inspection to follow up on a self-report unusual incident that was submitted to CCL Regional Licensing Office which occurred on 09/15/22 . LPA was met by Staff Sonia Tobar, upon entrance, LPA toured infant room and toddler room. Staff 2(S2) was caring for 2 infants Ms. Sonia was caring for 4 toddlers. During exit interview Director called, Maria Rodriguez , Area Director and requested her attendance at exit interview, Area Director arrived at approximately at 2:26pm A review of the Facility Personnel Report Summary conducted on 10/27/2022 indicates all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions. This is a follow up visit of the initial visit conducted on 09/19/22. The investigation consisted of staff interviews, review of facility files, review of video of incident. Interviews with S2 and S3 both indicated they had modeled changing diapers, which included, setting up the diaper and wipes on changing table prior to placing child on table and then to always have one hand on child. Both staff also indicated they had observed S1 changing diapers and following procedures. LPA was unable to interview S1. LPA P Rivas had attempted to interview Staff#1(S1) on 09/21/22, 10/11/22, 10/13/22 LPA left messages on telephone but no return call was received. Interview with Director, Rubi found the following; She was notified of the incident on 09/15/22 at 4:28 pm. Director states she modeled procedure for changing diaper and had also observed S1 correctly change a diaper. Director further reports that the facility's infant room was licensed with the same changing table as was used on 09/15/22. Director reports furniture, fixtures had not changed in infant room since approval of license only until after 09/21/22 Director (cont. page2)

SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Pat Rivas
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022

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: SERENDIB ANAHEIM LLC, DBA LITTLE MINDS LEARNING AC	FACILITY NUMBER: 304371468
	VISIT DATE: 10/27/2022

NARRATIVE

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stated she attempted to obtain information on C1's health but parent did not contact nor advise her of C1's status. However, on 09/15/22 C1's parent advised Director, that C1 was fine but they were going to take C1 to get checked.
LPA attempted to interview parent of C1 but parent was unwilling to be interviewed nor provide any documentation.

Review of the video shows time stamp of 14:59:20pm. However, the time stamp on cameras is 1 hour 15 minutes behind. Therefore, the incident occurred at 4:14pm, LPA verified time stamp was off by observing time stamp. Today at At 9:31am LPA observed live recording but time stamp listed as 8:14:22 .
LPA's observation of video of 09/15/22 incident, showed;
On video S1 was viewed in infant room caring for 3 infants. One infant was having a snack while seated on high chair, two infants were on floor. C1 was picked up by S1 and placed on changing table, S1 did not have diaper or wipes ready on table so S1was seen to bend down at knees, to open cabinet . Then S1 turned to look at child who was on the floor, who it appears had made a sound.(no sound available on video) At the same time as S1 looked away, S1 was bent down and there were no hands on C1 however, S1's hand appeared to be on the changing table. LPA observed C1 lift upper body, rolled and fell onto the floor.

Review of facility files;
C1's guardian signed C1 out at 4:20pm. S1 notified Director of incident at 4:28pm who in turn notified C1's parent of fall at approximately 4:30 via telephone call. Director reports she completed an ouch report but C1's parent took original. In reference to this incident the facility was previously cited on 09/19/22 for 101416.2(b)Infant Care Teacher Qualifications and Duties and 101419.2(b)(2) Infant Needs and Services Plan. Corrections were provided.

The following violations were revealed and is being cited in accordance with California Code of Regulations, Title 22, Division 12, Chapter 1, sub chapter 02, 101429(a)1 Responsibility for Providing Care and Supervision for Infants and 101439(h)2 Infant Care Center Fixtures, Furniture, Equipment and Supplies California Code of Regulations, B deficiency will be cited today. Civil Penalty Determination is pending.. Please refer to attached 9099 (D) .

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SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Pat Rivas
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022

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: SERENDIB ANAHEIM LLC, DBA LITTLE MINDS LEARNING AC	FACILITY NUMBER: 304371468
	VISIT DATE: 10/27/2022

NARRATIVE

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Appeal Rights were discussed. Ms. Lucero Rubi 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. Exit interview conducted and report was reviewed with the licensee

Exit interview conducted and report was reviewed with the director, Lucero Rubi.. 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.

SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Pat Rivas
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022

LIC809 (FAS) - (06/04)

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Document is an Amendment of Original Document on 02/14/2023 09:03 AM

Created By: Pat Rivas On 10/27/2022 at 01:23 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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: SERENDIB ANAHEIM LLC, DBA LITTLE MINDS LEARNING AC	FACILITY NUMBER: 304371468
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/27/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/31/2022 Section Cited CCR 101429(a)1	1 2 3 4 5 6 7	Responsibility for Providing Care and Supervision for Infants Each infant shall be constantly supervised and under direct visual observation and supervision by a staff person at all times. This requirement was not met as evidenced by review of video showing S1 looking away from C1 while C1 was ontop of changing	1 2 3 4 5 6 7	Director will write out changing diaper procedure and have teacher sign off and each teacher will demonstrate ability to follow correct procedure and send documentation to LPA by plan of correction date.
	8 9 10 11 12 13 14	table at which time C1 rolled off and fell. This poses a potential risk to the health and safety risk to children in care.	8 9 10 11 12 13 14
Type B 10/31/2022 Section Cited CCR101439(h)2	1 2 3 4 5 6 7	Infant Care Center Fixtures, Furniture, Equipment and Supplies Infant changing tables shall:Have raised sides at least three inches high. This requirement was not met as evidenced by review of changing table used on 09/15/22 which did not have all four sides raised at least three inches high.	1 2 3 4 5 6 7	Director has replaced changing table with a table that has all four sides that are 6 inches in length. LPA viewed new changing table in place. Corrected during visit
	8 9 10 11 12 13 14	This poses a potential health and safety risk to children in care.	8 9 10 11 12 13 14

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:

Rina Lopez

LICENSING EVALUATOR NAME:

Pat Rivas

LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022

LIC809 (FAS) - (06/04)

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