Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300611137
Report Date: 11/09/2017
Date Signed: 11/09/2017 12:02:52 PM

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:BARBUTO, SALLY ANNFACILITY NUMBER:
300611137
ADMINISTRATOR:BARBUTO, SALLY ANNFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 525-8056
CITY:FULLERTONSTATE: CAZIP CODE:
92832
CAPACITY:12CENSUS: 11DATE:
11/09/2017
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Sally Ann BarbutoTIME COMPLETED:
12:10 PM
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LPA Romero met with 2 adults and they had a census of 11 children in care. This plan of correction (POC) visit is being conducted today to provide licensee with Deficiency Cited Cleared letter and to deliver and acquire signatures for re-created reports dated 11/01/2017. Licensee emailed the POC for deficiencies cited on 11/01/2017 to LPA Romero on 11/03/2017.

No deficiencies were observed on today's visit. A review of children’s & staff records were reviewed to identify that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. The facility representative was informed that Licensing Quarterly Updates are available at www.ccld.ca.gov The facility representative may request to be added to an email list to receive a Quarterly Update by contacting the Child Care Advocate at childcareadvocatesprogram@dss.ca.gov.

An exit interview was completed with adult staff. The report was reviewed and discussed. Appeal Rights and deficiencies were discussed. The facility representative was provided a copy of their appeal rights and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Licensing office within 15 business days

The facility representative was informed that the “Notice of Site Visit” must be posted for 30 consecutive days. Failure to post will result in Civil Penalties of $100.00. The “Notice of Site Visit” must be posted on or adjacent to the door. Failure to post Type A reports for 30 day will result in a Civil Penalty of $100.00
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Christine RomeroTELEPHONE: (714) 703-2821
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2017
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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