Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 304270251
Report Date: 04/20/2018
Date Signed: 04/20/2018 10:30:49 AM


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/17/2018 and conducted by Evaluator Dean Valencia
PUBLIC
COMPLAINT CONTROL NUMBER: 06-CC-20180417163610
FACILITY NAME:MISSION BASILICA SCHOOLFACILITY NUMBER:
304270251
ADMINISTRATOR:BULLOCK, LAURAFACILITY TYPE:
850
ADDRESS:31641 EL CAMINO REALTELEPHONE:
(949) 234-1385
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY:45CENSUS: 23DATE:
04/20/2018
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Laura BullockTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Staff failed to provide adequate supervision
INVESTIGATION FINDINGS:
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A 10 day complaint inspection was conducted by Licensing Program Analyst Dean Valencia. LPA Valencia met with Director Laura Bullock to discuss the above allegation. During the inspection, the director was interviewed, a physical plant inspection was conducted, and census of children was taken. From the interview with the Director, and observations made during the physical plant inspection, LPA was able to determine that the facility staff fail to provide adequate supervision of children while playing in the outdoor play area. On today's visit, LPA observed two children behind a playhouse in the outdoor play area, not being visually supervised. This correlates with details of the allegation, and what may have led to an incident stated in the details of the allegation of staff failing to provide adequate supervision occurring. This constitutes a lack of supervision, and has been determined to be an immediate threat to the children's health and safety. The director stated that the facility will immediately make the back of the playhouse inaccessable, by placing baby gates on each side of the back of the playhouse. In additon, director stated she will speak with each preschool staff about supervising children in the outdoor play area.
(continued on LIC9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Dean ValenciaTELEPHONE: 714-703-2817
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2018
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 06-CC-20180417163610
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: MISSION BASILICA SCHOOL
FACILITY NUMBER: 304270251
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2018
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/21/2018
Section Cited
CCR
101229(a)(1)
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101229(a)(1) Care and Supervision. No child(ren) shall be left without the supervision, including visual observation, of a teacher at any time except as specified in sections 101216.2(e)(1) and 101230(c)(1).

On today's visit, LPA observed two
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The director stated the facility will place baby gates on both sides of the back side of the play hosue where a lack of supervision was observed. Photo proof of the baby gates installed to create inaccessability will be submitted by 4/21/20218. The director also stated she will speak withe her preschool
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children behind a playhouse in the outdoor play area, not being visually supervised. This correlates with details of the allegation, and what may have led to an incident stated in the details of the allegation of staff failing to provide adequate supervision occurring. This constitutes a lack of supervision, and has been determined to be an immediate threat to the children's health and safety.
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staff about maintaining compliant supervision of children while out on the outdoor play area.
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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: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Dean ValenciaTELEPHONE: 714-703-2817
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2018
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2018
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 06-CC-20180417163610
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: MISSION BASILICA SCHOOL
FACILITY NUMBER: 304270251
VISIT DATE: 04/20/2018
NARRATIVE
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The preponderance of evidence standard has been met, therefore the allegation has been found to be substantiated. California Code of Regulations Title 22 section 101229(a)(1) is being cited on the attached LIC 9099D.

Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100 per day. The licensee was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. First level appeal is to Regional manager, address is above on the report. This report is to be on file and accessible for public review at the facility for at least 3 years.

The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 9099D. Reports citing Type A violations are to be provided to parents/guardians of children currently in enrolled and to parents/guardians of children newly enrolled at the facility during the next 12 months. Parents/guardians must sign Form LIC9224 to be kept in each child's file.
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Dean ValenciaTELEPHONE: 714-703-2817
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2018
LIC9099 (FAS) - (06/04)
Page: 2 of 3