Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300611137
Report Date: 01/05/2018
Date Signed: 01/05/2018 04:41:15 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: 10DATE:
01/05/2018
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
03:06 PM
MET WITH:Sally Barbuto, LicenseeTIME COMPLETED:
04:55 PM
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LPA Romero toured the home inside and outside. Census was taken The overall census observed was 4 infants and 6 preschool children with 2 staff including the licensee. A review of staff criminal clearance records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. The purpose of the visit was relayed to the licensee. The home was clean, safe and in good repair at the time of the visit. The equipment and furniture were in good repair and free of sharp edges. Disinfectant, cleaning solutions, chemicals and/or poisons were locked or made inaccessible to the children.

Children's records were reviewed, and there was a separate, complete and current record for each child. Also provided was information about the E-Learning Modules available at https://ccld.childcarevideos.org.

A copy of the 2016 “A Child Care Providers Guild to Safe Sleep” was provided to the facility representative as well as copies of the following documents: Never Shake A Baby; Fire and Earthquake Drills Log; Unusual Incident Report Log; California Seat Belt Law; LIC 311D Forms to Keep In Your Family Child Care Home. Licensee is aware that all current and/or new staff moving forward are required to take the Mandated Reporter Training online which can be found at www.mandatedreporterca.com and is due to be completed by 03/31/2017 and every 2 years thereafter. A copy shall be kept in each staff file and will be reviewed during inspection times.

An exit interview was completed. The report was read out load, 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: 01/05/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2018
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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