300603522-4-12-2023-06-CC-NKTN-CQN5A4-20230406194632

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 300603522
Report Date: 04/06/2023
Date Signed: 04/12/2023 04:47:15 AM

Document Has Been Signed on 04/12/2023 04:47 AM - It Cannot Be Edited

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:	GRACE HARBOR CHURCH AND SCHOOL		FACILITY NUMBER:	300603522
ADMINISTRATOR:	REBEKAH BAY		FACILITY TYPE:	850
ADDRESS:	12881 NEWPORT AVENUE		TELEPHONE:	(714) 544-4431
CITY:	TUSTIN	STATE: CA	ZIP CODE:	92780
CAPACITY: 78	TOTAL ENROLLED CHILDREN: 78	CENSUS: 31	DATE:	04/06/2023
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Rebekah Bay, Director		TIME COMPLETED:	10:30 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	This is a follow-up proof of correction inspection that was made by Licensing Program Analysts (LPA) Tran and LPA Chan. LPAs met with Danielle Dizdull, Director of Admission, who guided the analysts on a tour of the facility. Census was taken as follow: 31 preschool children and 6 staff members. The Director Rebekah Bay arrived to meet with the LPAs 30 minutes later. LPAs informed the Director of the purpose of today's visit. A review of the Facility Personnel Report Summary on 04/06/2022 indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. An initial unannounced case management visit was conducted on 03/29/23 and a LIC 809 was completed. A type A deficiency was previously cited on a LIC 809D, in accordance with California Code of Regulations, Title 22, Division 12, Section 101229(a)(1) Responsibility for Providing Care and Supervision. This was a repeated violation that was previously cited on 03/09/2023. On 03/29/2023, a plan of correction was discussed with Director Rebekah Bay, in which, the Director provided a detailed plan to address the importance of providing supervision in care including supervision strategies, and ensuring all interior doors locked in sanctuary, while preschool children are on campus, and document of discussion with church administrative staff to keep door closed and locked, and kept all hazardous items in the office inaccessible for the children. LPAs observed the Notice of Site Visit was posted. During the inspection, 1 door out of 3 office doors in the Sanctuary was not locked. This unlocked door is to open into Room # 11, an off-limit room, and this room #11 has another exit door into the parking lot of the facility. During interview, Director said the facility was keeping this door locked, however, just today 04/06/23, when the LPAs came to inspect, the door was left unlocked. (Continue next page)

SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Nguyen K Tran
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

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: GRACE HARBOR CHURCH AND SCHOOL	FACILITY NUMBER: 300603522
	VISIT DATE: 04/06/2023

NARRATIVE

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(Page 2 of Report)

Based on LPA’s observation of the room #11's door was left unlocked on 04/06/23 and interview with Director, the facility failed to correct the Plan of Correction which was submitted on 03/29/23, a civil penalty was assessed until violation is corrected.

Appeal Rights were explained. The Director was provided a copy of appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. First level appeals should be sent to the regional manager to the address listed above. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with Director Rebekah Bay.

(End of Report)

SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Nguyen K Tran
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

LIC809 (FAS) - (06/04)

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