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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371581
Report Date: 07/10/2023
Date Signed: 07/10/2023 04:42:01 PM

Document Has Been Signed on 07/10/2023 04:42 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: 54CENSUS: 33DATE:
07/10/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Claudia Siem, DirectorTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) P Rivas conducted an unannounced case management visit to continue the investigation of an Unusual Incident that occurred on 05/25/23
Census was taken in individual classrooms and found 33 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 which was reported by facility. On 05/25/23 Child #1(C1) was given a snack(wheat thins) C1 has known allergies to wheat.
During today's visit LPA interviewed Staff #2(S2) and S3.
The following was found; C1 had an allergic reaction to wheat thins which were provided to her/him by S2 and S3 during extended day care hours. On 05/25/23 C1 attended extended daycare for the first time. Extended day care was being provided in C1's original classroom but not with her/his original staff. Interview with S1, S2 and S3 indicated that there was a list of children who had food allergies and it was posted in the extended day care room, including C1's allergies to wheat. Both S2 and S3 indicated they failed to review the list before providing wheat thins to C1. S1, S2 and S3 indicated that there was no verbal communication regarding C1's allergies. C1 was taken to emergency visit but did not return to facility. Interview with parents indicated C1 had to be kept under observation for a few days.

Based on the information gathered from the interviews conducted and record reviews, it was determined that C1 was provided wheat thins The allergy was known allergy and it had been documented.

cont page 2.

SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Pat Rivas
LICENSING EVALUATOR SIGNATURE: DATE: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/05/2023
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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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: PIPER IRVINE LLC.
FACILITY NUMBER: 304371581
VISIT DATE: 07/10/2023
NARRATIVE
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The facility was not in compliance of the California Code of Regulations, Title 22, Division 12. The following citations Food Service 101227(a)(7)(B), being cited on the attached 809D, and an immediate civil penalty was assessed.

LPA Rivas informed director Claudia Siem that this report dated 07/10/2023 for Type A citation which shall be posted for 30 consecutive days as there is immediate risk to the health, safety, or personal rights of children in care.

LPA Rivas informed the director Claudia Siem to provide a copy of this licensing report dated 0710/2023 Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Exit interview conducted and report was reviewed with the Director Claudia Siem. A notice of site visit was given and must remain posted for 30 days. Failure to post will result in civil penalties of $100.



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. First level appeals should be sent to the Regional Manager to the address listed above.
SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Pat Rivas
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/10/2023 04:42 PM - It Cannot Be Edited


Created By: Pat Rivas On 07/10/2023 at 03:43 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: PIPER IRVINE LLC.
FACILITY NUMBER: 304371581

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/11/2023
Section Cited
CCR
101227(a)(7)(B

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101227(a)(7)(B) Food Service
...(B) A child shall not be served any food to which the child's record indicates he/she has an allergy.
This requirement is not met evidenced by:
Based on LPA’s interview and record review
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Director reports she conducted an emergency meeting with staff and went over entire allergy protocol, reviewed allergy list provided in each class; and reviewed new protocol which required daily signature of all staff members present in classroom and director's signature at end of week; also
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 the facility served an allergic item (wheat thins) to C #1 during snack time, and the Item was listed LIC 702 Child's Preadmission Health History-Parents Report which was received upon admission by the facility. This poses an immediate risk to Health and Safety to children in care.
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extended day care is now being provided in each child's specific classroom. Also any child requiring an epi pen must provide own snack. Director to provide plan, copy of sign in sheet for emergency meeting by plan of correction date; Items can be emailed to LPA Rivas.

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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:Rina Lopez
LICENSING EVALUATOR NAME:Pat Rivas
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2023


LIC809 (FAS) - (06/04)
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