Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300611137
Report Date: 11/01/2017
Date Signed: 11/09/2017 11:41:40 AM

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:
11/01/2017
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Sally Ann Barbuto, LicenseeTIME COMPLETED:
11:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
** This is a re-created report dated 11/01/2017 due to computer error.**

Licensed Program Analyst (LPA) Romero and Complaint Specialist (CS) Hundley met with 2 staff and 11 children in care. During the course of the inspection the following deficiencies were noted:
Licensee failed to maintain records for child #11. Licensee had no documents on child #11 and did not know his last name or date of birth. Licensee says that child #1's mom is fostering child #11 and he was supposed to start kindergarten but there was a problem with the district. In addition, licensee self reported that on 02/03/2017 a day care child was brought in by his parents with a high fever. The child was outside and had a Seizure and fell to the floor. Child was taken to UCI Hospital via ambulance and the incident was not reported to CCL. Licensee does not have roster information on this child #12. Licensee failed to maintain current immunization records on child #4, child #7 and child #11. Licensee has failed to maintain an update roster for the current and past children in care for the last 3 years. During the course of the inspection licensee called foster parent for child #11 and she was able to give LPA the child's last name and date of birth. Based on LPAs observations the following violations were observed are being cited in accordance with California Code of Regulations, Title 22, Division 12, are being cited on the attached LIC 809D.

The facility representative was informed that the Criminal Record Statement (LIC 508) has been updated, and the facility must now use the new form with revised date 7/15. The facility representative was also informed that the LIC 508 must be submitted with all Criminal Background Clearance Transfer Request (LIC9182). 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 Continued on page 2
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Christine RomeroTELEPHONE: (714) 703-2821
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2017
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 4
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: BARBUTO, SALLY ANN
FACILITY NUMBER: 300611137
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/01/2017
Section Cited
CCR
102418(g)
1
2
3
4
5
6
7
Immunization. Licensee shall document and maintain each child’s immunizations as long as the child is enrolled. Licensee failed to maintain updated immunizations on child #4, #7, #11. This poses a potential Health and Safety risk to the children in care.
1
2
3
4
5
6
7
Licensee will complete blue immunization cards and email to LPA by 11/03/2017.
Type B
11/01/2017
Section Cited
CCR
102417(g)(8)
1
2
3
4
5
6
7
Operation of a Family Child Care Home. All homes shall have a current roster of the children. Licensee failed to have an updated roster and maintain those records for at least 3 years. This poses a potential Health and Safety risk to the children in care.
1
2
3
4
5
6
7
Licenese will update the records and provide LPA a coy via email by 11/03/2017.
Type B
11/01/2017
Section Cited
HSC
1597.467
1
2
3
4
5
6
7
Reporting requirements: Licensee failed to report an incident to CCL. Licensee self reported that on 02/03/2014 a child in care had a Seizure and fell, 911 was called and the child was taken via ambulance to UCI Hospital. This poses a potential Health and Safety risk to the children in care.
1
2
3
4
5
6
7
Licensee will complete a Unusual Incident Report form and licensee will write an emailed statement that states moving forward she will notify CCL of any unusual incidents using LIC 624B.
Type B
11/01/2017
Section Cited
CCR
102421(a)
1
2
3
4
5
6
7
Child's Records. The licensee shall maintain, in each child’s record, the signed and dated notice form LIC 995A, Parents Rights Notice. Licensee failed to have records for child #11. This poses a potential Health and Safety risk to the children in care.
1
2
3
4
5
6
7
Licensee will complete all required records for child #11 and send a copy to LPA via email.
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 LopezTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Christine RomeroTELEPHONE: (714) 703-2821
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2017
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2017
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: BARBUTO, SALLY ANN
FACILITY NUMBER: 300611137
VISIT DATE: 11/01/2017
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
** This is a re-created report dated 11/01/2017 due to computer error.**

Information on the additional nutrition training, immunization requirements for children, and Health Schools Act (http://www.cdpr.ca.gov/docs/pestmgt/schoolipm.htm) were provided. The facility representative was informed, and website given, about the California Child Care Disaster Plan has been posted to the UCSF California Childcare Health Program website: cchp.ucsf.edu/content/disaster-preparedness Also provided was information about the E-Learning Modules available at https://ccld.childcarevideos.org A copy of the Nutritious Beverage Bill was provided to the facility representative.
A copy of the 2016 “A Child Care Providers Guild to Safe Sleep” was provided to the facility representative, and website give below:
English: https//www.cdph.ca.gov/programs/SIDS/Doucments/SIDSchildcaresafesleep.pdf
Spanish: https//www.cdph.ca.gov/programs/SIDS/Doucments/ChildCareProvSleepSPAN2011.pdf

An exit interview was completed. 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: 11/01/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2017
LIC809 (FAS) - (06/04)
Page: 4 of 4
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: BARBUTO, SALLY ANN
FACILITY NUMBER: 300611137
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/01/2017
Section Cited
CCR
102417(g)(7)
1
2
3
4
5
6
7
Operation of a family day care home: Children's Emergency Information & Medical consent forms are missing from 1 child file. Licensee did not have any Emergency Information or Medical Consents for child #11. This poses a potential Health and Safety risk to the children in care.
1
2
3
4
5
6
7
Licensee will complete the required records for child #11 and email a copy to LPA.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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 LopezTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Christine RomeroTELEPHONE: (714) 703-2821
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2017
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2017
LIC809 (FAS) - (06/04)
Page: 2 of 4