Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300609833
Report Date: 06/19/2015 12:00:00 AM
Date Signed 06/19/2015 01:40:30 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:WARD, CLAUDIAFACILITY NUMBER:
300609833
ADMINISTRATOR:WARD, CLAUDIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 539-1044
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY:12CENSUS: 13DATE:
06/19/2015
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Claudia Ward - LicenseeTIME COMPLETED:
01:45 PM
NARRATIVE
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LPA Jane Cong-Huyen met with licensee, Claudia Ward, for a annual random visit using KIT1. The licensee was out of the home running errands when LPA arrived, few minutes later the licensee arrived home. The 2 adult assistants were caring for the children. Both the assistants did not have current CPR/First Aid. LPA toured areas of the home inside and outside and areas accessible to the children. The home is a one level home with 3 bedrooms and 2 bathrooms. Licensee stated that OFF LIMITS areas include: all bedrooms, left side of yard, storage shed and large workshop shed. The licensee has barricaded that area so the children does not have access to that area. Licensee acknowledged that children may never enter these off-limit areas. The census includes 13 daycare children with ages ranging from 1 month to 10 years old. (4 infants, 6 preschoolers and 3 school-age children) The licensee can only have up to 3 infants when she has more than 12 children in care. The licensee is out of ratio/capacity during today's visit. Licensee stated there are no new residents in the home since licensed. Also present at time of visit was the licensee's 2 adult assistants and adult roommate who have also been fingerprinted. Licensee stated that she is not registered with any Foster Care agency. A review of family member/staff records on this date indicates that all family members and/or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee was able to show proof of CPR (exp: 6/30/15) and First Aid (exp: 6/30/15) that is EMSA certified. LPA observed posted Parent's Rights and current disaster plan. LPA also reviewed children's records and children's roster. Fireplace contains a screen. Licensee stated there are no weapons in the home. LPA observed all sharp utensils, hazardous chemicals and medication are stored up high or in latched/locked cabinet which is inaccessible to children in care. Fire extinguisher, smoke and carbon monoxide detectors meet regulations. Licensee must provide 100% visual supervision when the children are in an unfenced area. The home has 1 small dog with immunization documents. No bodies of water at the home.

Deficiencies cited during today's visit. (See attached pages)
SUPERVISOR'S NAME: Dana WilliamsonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jane Cong-HuyenTELEPHONE: (714) 703-2818
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2015
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: WARD, CLAUDIA
FACILITY NUMBER: 300609833
VISIT DATE: 06/19/2015
NARRATIVE
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Random Annual, page 2

Exit interview was conducted. The Notice of Site Visit was posted. 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. LPA informed the licensee of how to access regulations and forms from CCLD websites: www.ccld.ca.gov or Myccl.ca.gov and/ or http://ccld.ca.gov/PG411.htm. This report is to be on file and accessible for public review at the facility for at least 3 years.

Licensee is advised to make this licensing report accessible to the public. If/when licensee/facility is cited any Type A citation/deficiencies, facility is to provide copies of the LIC809 and LIC809C/D pages with a receipt form LIC9224 within 24 hours or next day the child return to the facility. Facility Evaluation Report and LIC809D Facility Evaluation Deficiency Report with the Type A citation to parents/legal guardians of children in care and to parents/legal guardians of children newly enrolled at the facility during the subsequent 12 months after insurance. Licensee needs to keep verification of receipts in each child's file at the facility. Failure to post Type A report(s) for 30 days will result in civil penalty of $100.
SUPERVISOR'S NAME: Dana WilliamsonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jane Cong-HuyenTELEPHONE: (714) 703-2818
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2015
LIC809 (FAS) - (06/04)
Page: 2 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: WARD, CLAUDIA
FACILITY NUMBER: 300609833
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2015
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/23/2015
Section Cited
102416.5 (c)(2)
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Staffing Ratio/Capacity - A large family day care home may provide care for more than 12 children and up to and including 14 children, if all of the following conditions are met: No more than three infants are cared for during any time when more than 12 children are being cared for. Licensee was caring for 13 children with 4 infants in care.
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Licensee stated that the older children just got out of school and they usually are never here so she miscounted and thought she was okay with 4 infants. During today's visit, LPA observed the 3 school age children were picked up early. The licensee send a promise letter by due date stating that she will maintain her ratio/capacity at all times by due date 6/23/15.
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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: Dana WilliamsonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jane Cong-HuyenTELEPHONE: (714) 703-2818
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2015
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: WARD, CLAUDIA
FACILITY NUMBER: 300609833
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2015
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/03/2015
Section Cited
102416(c)
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Personnel Requirements. The Licensee and other personnel as specified shall complete training on preventive health practices including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866. Licensee was not present at the beginning of visit & both assistants did not have current CPR/First Aid cards during today's visit.
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Licensee stated that she and her assistants will be getting updated CPR & First Aid cards with EMSA and will send LPA copies (front & back) by due date on 7/3/15. In the mean time, the licensee must not leave the assistant(s) alone with the children until they have their updated EMSA cards.
Type B
06/26/2015
Section Cited
102369(b) (9)
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Application for initial license: Evidence of TB test clearance are not observed for Edwin Oliva. Evidence of a current tuberculosis clearance, not more than one year prior to or seven days after initial presence in the home, for any adult in the home during the time that children are under care.
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Licensee stated one of her assistants has TB but she can not find it in the file and the other one is getting her's read today. She will send both of the assistants' TB results to LPA by due date 6/26/15.
She understands that TB test results must be in the file prior to employment from now on.
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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: Dana WilliamsonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jane Cong-HuyenTELEPHONE: (714) 703-2818
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2015
LIC809 (FAS) - (06/04)
Page: 4 of 4