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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300603522
Report Date: 04/26/2023
Date Signed: 04/26/2023 02:44:19 PM

Document Has Been Signed on 04/26/2023 02:44 PM - 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 SCHOOLFACILITY NUMBER:
300603522
ADMINISTRATOR:REBEKAH BAYFACILITY TYPE:
850
ADDRESS:12881 NEWPORT AVENUETELEPHONE:
(714) 544-4431
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY: 78TOTAL ENROLLED CHILDREN: 78CENSUS: 57DATE:
04/26/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Rebekah Bay, DirectorTIME COMPLETED:
03:00 PM
NARRATIVE
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On 04/26/2023, Licensing Program Analysts (LPA) Tran and Chan conducted a case management visit at the facility to address a violation of Title 22, Reporting Requirement regulation. LPAs met with the Director Rebekah Bay and informed the Director of the purpose of the visit.

A review of the Facility Personnel Report Summary on 04/26/2023 indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

During an investigation on 04/06/23, it was discovered that the facility failed to report an unusual incident to the Department within the required time frame. The incident occurred on 03/31/23, when a child was found playing with a rat and was taken to urgent care for further check up. However, the facility did not submit any report regarding the incident to the Department within the 7 days.

When interviewed, Director admitted that the facility failed to report the incident in a timely manner.

Based on interview and record review, the following deficiency is observed in accordance with California Code of Regulations, Title 22, Division 12, Chapter 1, Section 101212 Reporting Requirements, is cited on the attached 809D. This is a repeated violation that was cited on 01/23/2023. A civil penalty of $250 was assessed due to the repeated violation.

Exit interview was conducted. The Notice of Site Visit was posted. Director was advised the Notice of Site Visit must be posted for 30 days or 100$ Civil Penalty will be assessed.

(End of Report)
SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Nguyen K Tran
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2023
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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Document Has Been Signed on 04/26/2023 02:44 PM - It Cannot Be Edited


Created By: Nguyen K Tran On 04/26/2023 at 01:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: GRACE HARBOR CHURCH AND SCHOOL
FACILITY NUMBER: 300603522

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/26/2023
Section Cited
CCR
101212(d)(1)

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101212 Reporting Requirements...(d) Upon the occurrence... a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours... In addition, a written shall be submitted to the Department within seven days.
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Director states that she will submit a statment of understanding of the Reporting Requirement regulation to LPA by due date.
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This requirement is not met evidenced by:
Based on LPA's record review and interview , facility failed to submit an unusual incident report to Community Care Licensing Department regarding this incident, this poses a potential risk to the health, safety and personal rights of persons 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 Lopez
LICENSING EVALUATOR NAME:Nguyen K Tran
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2023


LIC809 (FAS) - (06/04)
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