Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304370736
Report Date: 04/29/2016
Date Signed 04/29/2016 10:40:02 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:
304370736
ADMINISTRATOR:WALSWICK, ERICFACILITY TYPE:
840
ADDRESS:23721 LA PALMA AVENUETELEPHONE:
(714) 694-0901
CITY:YORBA LINDASTATE: CAZIP CODE:
92887
CAPACITY:14CENSUS: 8DATE:
04/29/2016
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Lyndy Moore & Eric WalswickTIME COMPLETED:
10:45 AM
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The purpose of this visit was to conduct a Case Management Evaluation of the facility. LPA Hanson and LPA Taylor toured the facility inside and outside. Census was taken. The overall census observed was 1 school-age staff and 8 school-age children. A review of staff criminal clearance records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

While present at the facility it was observed that the Private School Affidavit that it is only for 6 children, and there were 8 children present. LPA Hanson and LPA Taylor discussed with the facility representative that the facility will need to operate as a licensed program all day until the Private School Affidavit can be update in October 2016. It was discussed that the children can not be sent to the restroom alone, they need to be escorted.

In the areas that were evaluated, no deficiencies were observed of the California Code of Regulations, Title 22, Division 12 at the time of the visit.

An exit interview was completed. 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 to the parents/guardians of children newly enrolled at the facility during the next 12 months. 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: Dana WilliamsonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Judy HansonTELEPHONE: (714) 703-2822
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2016
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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