Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304370736
Report Date: 12/20/2017
Date Signed 12/20/2017 11:02:18 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:HEMENWAY, HANNAHFACILITY TYPE:
840
ADDRESS:23721 LA PALMA AVENUETELEPHONE:
(714) 694-0901
CITY:YORBA LINDASTATE: CAZIP CODE:
92887
CAPACITY:30CENSUS: 0DATE:
12/20/2017
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:01 AM
MET WITH:Hannah Hemenway, Erin McVay & Katrina JensTIME COMPLETED:
11:00 AM
NARRATIVE
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LPA Hanson toured the facility inside and outside. AT the time of the visit there were no school-age children present. 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.

The facility was clean, safe and in good repair at the time of the visit. All floors were clean and safe. The restrooms, equipment and furniture was in good repair and free of sharp edges. Disinfectant, cleaning solutions and other poisons were locked or made inaccessible to the children. Food storage, sign in/out, 1st aid/CPR, carbon monoxide detector, and drinking water were inspected. Children's records were reviewed, and there was a separate, complete and current record for each child. Children have been signed in and out with legal signatures. Staff flies were reviewed, and educational background and health screenings were present. Staff were missing immunization’s. There are no bodies of water present at the facility. This facility provides Incidental Medical Services (IMS), and a copy is on file with the Licensing Office. 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

Based on LPA's observations the following violation were observed is being cited in accordance with California Code of Regulations, Health & Safety 1596.7995(a)(1), is being cited on the attached LIC 809D.
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Judy HansonTELEPHONE: (714) 703-2822
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2017
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: 304370736
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/22/2018
Section Cited
CCR
1596.7995(a)(1)
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Immunization's. Commencing September 1, 2016, a person shall not be employed/volunteer at a day care center if she or he has not been immunized against influenza, pertussis, and measles. Each employee/volunteer shall receive an influenza vaccination between August 1 and
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The director plans to resolve the violation by submitting copies of the missing information to the Licensing office by the due date.
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December 1 of each year. There were several staff missing some or all of the required immunization's. This poses a potential Health and Safety risk to the children in care.
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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: Rina LopezTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Judy HansonTELEPHONE: (714) 703-2822
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2017
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2017
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: 304370736
VISIT DATE: 12/20/2017
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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). The facility representative was informed that Licensing Quarterly Updates are available at www.ccld.ca.gov The facility representative may request to be added to an email list to receive a Quarterly Update by contacting the Child Care Advocate at childcareadvocatesprogram@dss.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 A copy of the Nutritious Beverage Bill was provided to the facility representative.
A copy of the 2016 “A Child Care Providers Guild to Safe Sleep” was provided to the facility representative, and website give below:
English: https//www.cdph.ca.gov/programs/SIDS/Doucments/SIDSchildcaresafesleep.pdf
Spanish: https//www.cdph.ca.gov/programs/SIDS/Doucments/ChildCareProvSleepSPAN2011.pdf

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.

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 day will result in a Civil Penalty of $100.00

Documents/Information to be updated and returned to the Licensing Office;
- Personnel Report (LIC 500)
- Emergency Disaster Plan (LIC 610)
- Administrative Organization (LIC 309)
- Fire Drill Log
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Judy HansonTELEPHONE: (714) 703-2822
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2017
LIC809 (FAS) - (06/04)
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