Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304300901
Report Date: 04/25/2017
Date Signed: 04/25/2017 10:12:30 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:TRAN-BELLEBILLE, PATRICIAFACILITY NUMBER:
304300901
ADMINISTRATOR:TRAN-BELLEVILLE, PATRICIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 891-6918
CITY:GARDEN GROVESTATE: CAZIP CODE:
92845
CAPACITY:14CENSUS: 9DATE:
04/25/2017
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Patricia Tran-BellevilleTIME COMPLETED:
10:20 AM
NARRATIVE
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An inspection was conducted at the facility by LPA, Dean Valencia. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. There are presently 3 adults living in the home.

During today’s inspection the home and grounds were toured and the licensee was operating within the licensed capacity. The facility was operating out of ratio, see attached LIC809D. There were 6 infants in care, and 3 preschool age children in care. Operating hours are 6am to 6pm, Mon–Fri. The floor plan was verified. The licensee's pediatric CPR/First Aid certification is current, which expires 8/2018. Items which could pose a danger to children (detergents, cleaning compounds, and medications) were stored out of the reach of children. Poisonous items are locked in the garage. There is a working carbon monoxide detector, smoke detector, and fire extinguisher in the home. The licensee has a current roster of children in care. The facility has conducted an emergency drill within the past six months. The licensee stated there are no firearms and/or other dangerous weapons in the home and none were observed during today's visit. The children use the backyard as the outdoor play area, and it is completely fenced. The outdoor play area is free from hazards. There are no bodies of water on the premises. Children's records were reviewed, and one record was found to be missing an immunization record. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm . Proof of immunization against pertussis and measles for licensee(s)/assistants/volunteers were reviewed and within compliance of SB 792.

continued on LIC809C.
SUPERVISOR'S NAME: Marian WallmeierTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Dean ValenciaTELEPHONE: 714-703-2817
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2017
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: TRAN-BELLEBILLE, PATRICIA
FACILITY NUMBER: 304300901
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/09/2017
Section Cited
102418(g)
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102418(g) Immunization. Licensee shall document and maintain each child’s immunizations as long as the child is enrolled.

One child in care did not have immunization records available for review. This is a potential threat to children's health and safety.
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Licensee stated she will submi the child's immunization record, by 5/9/2017.
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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: Marian WallmeierTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Dean ValenciaTELEPHONE: 714-703-2817
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2017
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: TRAN-BELLEBILLE, PATRICIA
FACILITY NUMBER: 304300901
VISIT DATE: 04/25/2017
NARRATIVE
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Facility was advised on how to receive notifications for quarterly updates and provided with Child Care Advocate contact information: childcareadvocatesprogram@dss.ca.gov A copy of the 2016 “A Child Care Providers Guild to Safe Sleep” was provided to the facility representative. English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf Spanish: https//www.cdph.ca.gov/programs/SIDS/Documents/ChildCareProvSleepSPAN2011.pdf
Exit interview was conducted. Report reviewed and discussed. Notice of Site Visit was posted during the visit. 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. Appeal rights provided and explained. The director/licensee was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. Licensee was informed of how/where to access regulations and forms from CCLD website: www.ccld.ca.gov. 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 809D. The licensee was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights.
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: Marian WallmeierTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Dean ValenciaTELEPHONE: 714-703-2817
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2017
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: TRAN-BELLEBILLE, PATRICIA
FACILITY NUMBER: 304300901
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/26/2017
Section Cited
102416.5(d)(1)
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For a Large Family Child Care Home, the maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home, including children under age 10 who reside at the licensee's home and the assistant provider's children under age 10, shall be either:
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Licensee stated she will submit a detailed plan for how she will return to compliance and remain within ration from here on out. The plan will be submitted by 4/26/2017.
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Twelve children, no more than four of whom may be infants.

Of the nine children in care during the inspection, six were infants. This is an immediate threat to children's health and safety.
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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: Marian WallmeierTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Dean ValenciaTELEPHONE: 714-703-2817
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2017
LIC809 (FAS) - (06/04)
Page: 2 of 4