Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300613936
Report Date: 01/25/2017
Date Signed 01/25/2017 02:49:21 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:MISSION VIEJO CHRISTIAN KIDS CLUBFACILITY NUMBER:
300613936
ADMINISTRATOR:SWEETSER, JOHNFACILITY TYPE:
840
ADDRESS:27192 JERONIMO ROADTELEPHONE:
(949) 465-1954
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92692
CAPACITY:175CENSUS: 30DATE:
01/25/2017
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:DirectorTIME COMPLETED:
03:15 PM
NARRATIVE
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(3) The purpose of this visit was to conduct an annual evaluation of the facility. Licensing Program Analyst (LPA) Malek met with director, John Sweetser at the time of the visit. LPA toured the facility inside and outside with Mr. Sweetser. Census was taken. There were a total of 23 preschool children with 3 staff observed in room 305 on the 2nd floor. During LPA's visit, Another group of 7 children with additional 2 staff joined this group of children. Today is early dismissal for the local School District. Children are picked up from elementary school at different trimmings. Some of the classrooms are shared with Mission Viejo Christian Preschool which is located on the same premises. The preschool classrooms are not in use in the afternoon. The classrooms were checked. (Rooms 204, 207, 208, 209, 210, 301, 302, 303, and 304). The assembly room was also inspected. Medication, food storage, sign in/out, 1st aid/CPR, cleaning supplies storage, carbon monoxide detector, drinking water, and fire drill log were inspected. Facility met all posting requirements. Children's files and staff records were reviewed.
A review of staff records on this date indicates that all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.
This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. 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

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.
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2800
LICENSING EVALUATOR NAME: Mahnaz MalekTELEPHONE: (714) 703-2810
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2017
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 3


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: MISSION VIEJO CHRISTIAN KIDS CLUB
FACILITY NUMBER: 300613936
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/27/2017
Section Cited
H&S 1596.622
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Employees or volunteers at day care center; immunization requirements; records; exemptions:
Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and Influenza.
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The director stated he would arrange for staff to have the required immunization or he would send the declined statement from staff that they refused this since it was optional for staff. The director will send a list of staff to show their records with date vaccine administered
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Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. Some employees have no proof of MMR, Pertussis, and immunization against influenza. There were no records of statement of declining on file either. Names were given. This is a potential hazard to the safety of children.
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or decline date(influenza only) from staff to our office by the due date of 2/27/2017.
Type B
01/31/2017
Section Cited
101226.e(1)(A)
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Health Related Services- Prescription medications shall be administered in accordance with the label directions as prescribed by the child's physician. Label for prescribed inhaler medication was missing. This poses a potential hazard to the health and safety of children. Name was given to director.
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The director will send a copy of correction to our office. The medication shall be labeled with the physician's information and child's information. A picture will be emailed as proof for this deficiency to our office by the due date 1/31/2017
Type B
01/31/2017
Section Cited
101226(e)(6)
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Health-Related Serivces: When no longer needed by the child, or when the child withdraws from the center, all medications shall be returned to the child's authorized representative or disposed of after an attempt to reach the authorized representative.. One Epiphen medication was expired on 11/2016
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The director will coordinate it with the parent to get an updated one. A picture of the box to show the current expiration on it will be sent to our office.
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) 703-2800
LICENSING EVALUATOR NAME: Mahnaz MalekTELEPHONE: (714) 703-2810
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2017
LIC809 (FAS) - (06/04)
Page: 3 of 3


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: MISSION VIEJO CHRISTIAN KIDS CLUB
FACILITY NUMBER: 300613936
VISIT DATE: 01/25/2017
NARRATIVE
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An exit interview was completed. The report was reviewed and discussed. The facility representative was provided a copy of their appeal rights (LIC 9058 12/15) 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 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) and a picture ID to our office for association. The facility representative was informed that Licensing Updates are available at www.ccld.ca.gov

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

The following website link for infant's safe sleep information in English and Spanish was given. www.cdph.ca.gov/programs/sids/documents/sidschildcaresafesleep.pdf
In Spanish
www.cdph.ca.gov/programs/sids/documents/childcareprovsleepspan2011.pdf
Also a copy of child care provider's guide to safe sleep pamphlet was given to the director at this visit.

In the areas that were evaluated, the following deficiencies were observed of the California Code of Regulations, Title 22, Division 12 at the time of the visit. (Please see LIC 809 D)
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2800
LICENSING EVALUATOR NAME: Mahnaz MalekTELEPHONE: (714) 703-2810
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2017
LIC809 (FAS) - (06/04)
Page: 2 of 3