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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371581
Report Date: 05/31/2023
Date Signed: 05/31/2023 03:13:34 PM

Document Has Been Signed on 05/31/2023 03:13 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:PIPER IRVINE LLC.FACILITY NUMBER:
304371581
ADMINISTRATOR:SIEM, CLAUDIAFACILITY TYPE:
850
ADDRESS:8673 IRVINE CENTER DRIVETELEPHONE:
(310) 451-4600
CITY:IRVINESTATE: CAZIP CODE:
92618
CAPACITY: 185TOTAL ENROLLED CHILDREN: 70CENSUS: 38DATE:
05/31/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Claudia Siem, Director & Kim Soria, Asst DirectorTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) P Rivas conducted an unannounced case management visit to investigate the self reported incident of 05/25/23. LPA was met and assisted by Director, Claudia Siem and Asst. Director, Kim Soria.

Census was taken in individual classrooms and found 38 pre school children and 9 teachers.

A review of the Facility Personnel Report Summary indicates adult residents, who require caregiver background check clearances, transfers, exemptions have been obtained and they are cleared.

An incident occurred on 05/25/23 in which Child #1(C1) was given a snack for which C1 is allergic to. C1's mother had arrived to pick up C1 , C1 advised mother that s/he had a particular snack after which C1's mother proceeded to obtain medication from Director's office and administered it and left. Director reports that C1 was taken to emergency but not admitted and child has not returned to school. Staff #1, 2 and 3 were given corrective actions.
During today's visit LPA reviewed, files for 3 staff, one child, interviewed 1 staff.

Due to insufficient information available at this time LPA will continue investigation at a further date.

Exit interview conducted with facility representative. The report was reviewed and discussed. Appeal Rights were discussed. Director was provided 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 the Regional Office within 15 business days.

Director was informed that the "Notice of Site Visit" must be posted for 30 consecutive days. The Notice of Site Visit must be posted on or adjacent to the door. Failure to post will result in Civil Penalties of $100.00.

SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Pat Rivas
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2023
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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