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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371499
Report Date: 03/25/2022
Date Signed: 03/25/2022 03:56:03 PM

Document Has Been Signed on 03/25/2022 03:56 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:KIDDIE ACADEMY OF MISSION VIEJOFACILITY NUMBER:
304371499
ADMINISTRATOR:DEMPSEY, KAYLAFACILITY TYPE:
850
ADDRESS:25521 MUIRLANDS BLVD.TELEPHONE:
(949) 380-6868
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 120TOTAL ENROLLED CHILDREN: 120CENSUS: 20DATE:
03/25/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Facility Representative : Du, YuanlongTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Desai, Ketki conducted an unannounced Case Management Licensee initiated inspection at the site.

Facility is withdrawing the application for adding the Toddler option as this time.

LPA had conducted an unannounced inspection on 3/18/22 and a Notice of Site visit was issued.
On today's unannounced inspection, Upon entrance LPA observed, the Notice of Site visit was not posted by the facility.

Deficiency (Type B) issued for failure to post the Notice of Site visit and Civil penalty was assessed on today's inspection

Appeal rights presented to Mr. Du, Yuanlong

Exit interview conducted

Notice of Site visit : A notice of site visit was given and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE: DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2022
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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Document Has Been Signed on 03/25/2022 03:56 PM - It Cannot Be Edited


Created By: Ketki Desai On 03/25/2022 at 03:27 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: KIDDIE ACADEMY OF MISSION VIEJO
FACILITY NUMBER: 304371499

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/25/2022
Section Cited

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The licensing report provided by the department shall be posted immediately upon receipt, adjacent to the postings required pursuant to Section 1596.817 and on, or immediately adjacent to, the interior side of the main door to the facility and shall remain posted for 30 consecutive days. On 3/25/22, LPA upon entrance into the
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facility observed the Notice of site visit was not posted by the facility representative issued on 3/18/2022. Civil penalty is being assessed for failure to post the Notice of Site visit.
This is a potential risk to Health and Safety to the 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:Thuy Ho
LICENSING EVALUATOR NAME:Ketki Desai
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2022


LIC809 (FAS) - (06/04)
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