Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304370734
Report Date: 02/13/2018
Date Signed 02/13/2018 11:37:54 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:FUN 4 KIDS PRESCHOOLFACILITY NUMBER:
304370734
ADMINISTRATOR:HEMENWAY, HANNAHFACILITY TYPE:
850
ADDRESS:23721 LA PALMA AVENUETELEPHONE:
(714) 694-0901
CITY:YORBA LINDASTATE: CAZIP CODE:
92887
CAPACITY:76CENSUS: 36DATE:
02/13/2018
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Hannah Hemenway-DirectorTIME COMPLETED:
12:00 PM
NARRATIVE
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A case management inspection was conducted in regard to a self reported incident. LPA toured the facility and observed 36 preschool children with 4 staff and the director. 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.

During initial inspection LPA Taylor interviewed 4 children, interviewed 1 staff and reviewed files. No other children were interviewed regarding incident due to the age of the child who are too young to verbally communicate.

During today's visit LPA Taylor interviewed 6 staff and reviewed records.

According to the self reported incident report Parent #1 notified the Director Child #1 fractured their
elbow while in care on 1/25/18. The staff deny any knowledge of Child #1 falling or being injured at the school that day. It was disclosed during interviews Child #1 appeared fine upon arrival to school the morning of 1/25/18. It was disclosed Child #1 was not their normal self later that day, but showed no signs of being injured. Upon pick up from school Child #1 told Parent #2 they had hurt their elbow. During interviews it was disclosed Child #1 told their Parents they had injured left arm while on the slide at school. Child #1 was taken to the doctor by parents and diagnosed with a fractured elbow.

Based upon information gathered from interviews, the staff is not aware how a child sustained an injury; facility is cited for lack of supervision resulting in an injury.
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Andrea TaylorTELEPHONE: (714) 703-2820
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2018
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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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: FUN 4 KIDS PRESCHOOL
FACILITY NUMBER: 304370734
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2018
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
02/13/2018
Section Cited
CCR
101229(a)(1)
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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).
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The director will have a meeting with the staff to review supervision. The director will put the agenda in writing and have staff sign verifying meeting. The agenda and signatures will be submitted to LPA.
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It was determined a child in care sustained a fracture of the left elbow at school, and no staff are aware how the injury occur.
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andrea.taylor@dss.ca.gov
(714) 703-2831 Fax

A immediate civil penalty of $500 was assessed today.
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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: Andrea TaylorTELEPHONE: (714) 703-2820
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2018
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2018
LIC809 (FAS) - (06/04)
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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: FUN 4 KIDS PRESCHOOL
FACILITY NUMBER: 304370734
VISIT DATE: 02/13/2018
NARRATIVE
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An exit interview was completed. The report was reviewed and discussed. Appeal Rights and deficiencies were 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.

If the facility receives a Type A violations, the licensee shall post and provide copies of the report to parents/guardians of the children in care at the facility by the next business day, and shall provide to the parents/guardians of children newly enrolled at the facility during the next 12 months. In addition, the licensee shall immediately post upon receipt the Proof of Correction for 30 consecutive days. The licensee is to keep Acknowledgement Receipt (LIC 9224) signed by parents in each child’s file.

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 DAYS WILL RESULT IN A CIVIL PENALTY OF $100.00.
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Andrea TaylorTELEPHONE: (714) 703-2820
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2018
LIC809 (FAS) - (06/04)
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