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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334807214
Report Date: 07/11/2023
Date Signed: 11/16/2023 12:10:59 PM

Document Has Been Signed on 11/16/2023 12:10 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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:JAN PETERSON CHILD DAY CARE CENTERFACILITY NUMBER:
334807214
ADMINISTRATOR:LINDA BEDNARFACILITY TYPE:
850
ADDRESS:26895 BRODIAEA AVENUETELEPHONE:
(951) 601-9200
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92555
CAPACITY: 92TOTAL ENROLLED CHILDREN: 92CENSUS: 44DATE:
07/11/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:29 AM
MET WITH:Victoria De LavegaTIME COMPLETED:
10:20 AM
NARRATIVE
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Licensing Program Analysts (LPA's) Sumayya Habeebulla and Linda Almaraz arrived at the facility to conduct an inspection, for a separate an unrelated issue and were greeted by Assistant Director Victoria De Lavega. After touring the facility, taking a census, and verifying staff associations, LPAs found the facility to be out of compliance due to a staff not being fingerprint cleared and associated to the facility.

During today's inspection, Ms.De Lavega was informed about the status for the staff member. The staff member left the facility when LPAs were present. Staff's date of hire was on 03/15/23 as per records review and interview.

The Licensee can submit transfer forms to associate new individuals or to disassociate at: Associations_Disassociations862@dss.ca.gov

The facility was cited: 101170(e)(2) Criminal Record Clearance. 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: (2) Request a transfer of a criminal record clearance as specified in Section 101170(f). – Deficiency has been dismissed - LPA confirmed that staff had been fingerprinted and did not receive letter of “Incomplete Fingerprint Submission.”



An exit interview was conducted, appeal rights discussed, and a copy of this report was provided to the Assistant Director.
A copy of this report must be made available to the public, upon their request, for 3 years.

The Notice of Site Visit must be posted for 30 days.

Failure to keep these posted for the entire 30 days will result in an immediate $100 civil penalty for each day.

SUPERVISORS NAME: Carlos Martinez
LICENSING EVALUATOR NAME: Sumayya Habeebulla
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2023
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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Document Has Been Signed on 11/16/2023 12:11 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 10/09/2023 02:55 PM


Created By: Sumayya Habeebulla On 07/11/2023 at 09:31 AM
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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: JAN PETERSON CHILD DAY CARE CENTER
FACILITY NUMBER: 334807214

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
07/05/2023
Section Cited
CCR
101170(e)(2)

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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: (2) Request a transfer of a criminal record clearance as specified in Section 101170(f).
Based on file review and interviews....
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Assistant Director agreed to obtain fingerprint clearance for S1 before the staff can return to work at the facility and submit the proof to the department by the POC due date.
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This is an amended report. Deficiency Dismissed.

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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:Carlos Martinez
LICENSING EVALUATOR NAME:Sumayya Habeebulla
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023


LIC809 (FAS) - (06/04)
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