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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 300603522
Report Date: 05/07/2025
Date Signed: 05/07/2025 02:36:24 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/28/2025 and conducted by Evaluator Anna Francesca Chan
PUBLIC
COMPLAINT CONTROL NUMBER: 06-CC-20250228143501
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:78CENSUS: 44DATE:
05/07/2025
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Director Cynthia EstepTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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7
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9
Buildings and Grounds (Safety)
Daily Inspection for Illness
Staff smelled like cannabis or marijuana while children are in care.
INVESTIGATION FINDINGS:
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On 5/07/2025, at 11:30AM Licensing Program Analyst (LPA) Anna Chan conducted an unannounced Complaint investigation to deliver findings of the investigation initiated on 3/7/2025. Upon arrival, LPA met with Director, Cynthia Estep. LPA informed director of the purpose of visit and was led on walkthrough of the facility. Census was taken. LPA observed 5 staff and 44 preschool children.

The Department received a complaint on 2/28/2025 alleging (1) Staff does not ensure play area is in good and safe condition. (2) Staff did not ensure infectious disease is managed

Based on LPAs observations on 3/7/25, the toys in the play yard have broken doors with sharp plastic edges. There were a spool wooden tables with protruding wood edges and worn-out top which can splinter the children. There were worn-out and ripped colored play mats on the side of the play area which is a tripping and health hazard as mats were ripped and sponges were showing.
Page 1 of 2
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Martha Malane
LICENSING EVALUATOR NAME: Anna Francesca Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 06-CC-20250228143501
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: GRACE HARBOR CHURCH AND SCHOOL
FACILITY NUMBER: 300603522
VISIT DATE: 05/07/2025
NARRATIVE
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Based on record review, there were at least 3 confirmed cases of preschool children who were infected with pink eye or conjunctivitis. Based on interviews with staff, staff stated there were confirmed cases of pink eye or conjunctivitis between students and teachers during the week of 2/21/25. Staff stated they did not notify the department about the infectious disease within 24hrs or by written report within 7 days of incidents or outbreak.

During the course of this investigation, it was discovered that facility staff 7 (S7) smelled like cannabis or marijuana while children are in care.

During an interview with Adult 1 (A1), A1 stated they could smell in the room and Staff 7 (S7) smelled like cannabis. S7 stated they do not use cannabis or marijuana during operating hours. S7 stated the smell was stuck on the shirt that they wore and they will ensure they will change their clothes prior to arriving at the facility so this does not happen again.

Based on record review, there was a warning notice from the facility in S7’s file about drug and alcohol use that violated thire employee handbook.

None of the children interviewed disclosed any information that supported the allegations.

Based on observations, records reviewed and interviews conducted, the preponderance of evidence standard has been met, therefore the allegations were SUBSTANTIATED. A substantiated finding means the allegations were valid because the preponderance of the evidence standard has been met. See LIC9099D for 3 Type B deficiencies cited.

An exit interview was conducted, report and deficiencies were reviewed and discussed with Director, Cynthia Estep. The Notice of Site Visit was posted during the visit. The director was informed that the Notice of Site Visit must be posted for 30 consecutive days. The director was provided a copy of their appeal rights (LIC 9058 01/16)
SUPERVISORS NAME: Martha Malane
LICENSING EVALUATOR NAME: Anna Francesca Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 06-CC-20250228143501
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 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: 05/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/09/2025
Section Cited
CCR
101238(3)
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Buildings and Grounds (a) The child care center shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children, employees and visitors.
This requirement was not met as evidenced by:

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The director stated they will discard broken toys. Photos will be sent to LPA as proof of actio by due date of 6/9/25. The spool wooden table was discarded upon LPAs arrival on this date.
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Based on obveservation, there were broken toys in the play yard such a broken plastic kitchen toys, there is a wooden spool table that has protruding wood which could splinter children in care. Mats used was ripped and shows off sponges that can cause tripping hazard. This is potential risk to health safety of children in care.
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Type B
06/09/2025
Section Cited
CCR
101212(d)
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101212(d) Reporting Requirement (d) Upon the occurrence, during the operation of the child care center... a report shall be made to the Department by telephone or fax within the Department's next working day...and within seven days following the occurrence of such event.

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Director stated they will send action plan to prevent this from happening again by due date of 6/9/25
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Based on interview and record review, there were at least 3 confirmed cases of preschool children who were infected with pick eye or conjunctivitis. The Department was not notified of th outbreak.
This is potential risk to health safety of 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.
SUPERVISORS NAME: Martha Malane
LICENSING EVALUATOR NAME: Anna Francesca Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/28/2025 and conducted by Evaluator Anna Francesca Chan
COMPLAINT CONTROL NUMBER: 06-CC-20250228143501

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:78CENSUS: 44DATE:
05/07/2025
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Director Cynthia EstepTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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2
3
4
5
6
7
8
9
Director Qualifications
Ratio
Staff Qualifications
Buildings and Grounds (Shade)
Buildings and Grounds (Cushioning)
Children not properly cleaned and wiped (Diapering)


INVESTIGATION FINDINGS:
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On 5/7/2025, at 11:30AM Licensing Program Analyst (LPA) Anna Chan conducted an unannounced Complaint investigation inspection to deliver findings of the investigation initiated on 3/7/2025. Upon arrival, LPA met with Director, Cynthia Estep. LPA informed director of the purpose of visit and was led on walkthrough of the facility and a census was taken. LPA observed 5 staff and 44 preschool children.

The Department received a complaint on 2/28/2025 alleging (1) Licensee did not ensure a qualified Director is on site during day care hours, (2) Facility staff are operating out of ratio (3) Licensee is allowing unqualified staff to provide care to day care children (4) Licensee does not ensure facility play area has adequate shading, (5) Staff are not maintaining soft cushioning for the play area.

Page 1 of 2
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Martha Malane
LICENSING EVALUATOR NAME: Anna Francesca Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 06-CC-20250228143501
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: GRACE HARBOR CHURCH AND SCHOOL
FACILITY NUMBER: 300603522
VISIT DATE: 05/07/2025
NARRATIVE
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(1) The facility informed the Department on 2/21/25 about the director change in the facility. (2) Staff interviewed stated they are always in ratio and would use their walkie talkie to ask for backup. Based on observation, the facility is operating within its licensed capacity and compliance staffing ratios (3) Staff interviewed stated they have not witness any unqualified staff providing care or being left alone with day care children.

Based on observation and record review, staff present during the complaint inspection are qualified to supervise children.

(4) Based on LPA’s observation, there is adequate shading in the preschool yard, there is the side by the wall and classroom that provides shade to outdoor area. (5) LPA observed there is adequate cushioning like sand and grass in the climbing structure enough to absorb falls.

(6) During the course of this investigation, there was a concern from an adult that children are not properly cleaned and wiped while in care. Based on staff interviews, staff stated they change the children while standing up and makes sure they clean the area properly. Staff stated they check the diapers at the end of the day and log them in the app for parents to see.

Based on observations, conflicting information, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations were UNSUBSTANTIATED.

An exit interview was conducted, report was reviewed and discussed with Director, Cynthia Estep. The Notice of Site Visit was posted during the visit. The director was informed that the Notice of Site Visit must be posted for 30 consecutive days. The director was provided a copy of their appeal rights (LIC 9058 01/16)
SUPERVISORS NAME: Martha Malane
LICENSING EVALUATOR NAME: Anna Francesca Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 06-CC-20250228143501
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 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: 05/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/09/2025
Section Cited
CCR
101216(a)
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101216(a) Personnel Requirements
(a) Child care center personnel shall be competent to provide the services necessary to meet the individual needs of children in care... This requirement was not met as evidenced by:
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Director stated they have given a warning note to S7 and termination of employment will follow if policy is not followed. A documented plan of action will be submitted by the director to LPA by due date of 6/9/25
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Based on interview and record review, there was a warning notice on S7’s file about drug and alcohol use that violated their employee handbook. Based on interview, adult 1 stated they could smell in the room and S7 like cannabis. Based on S7 interview, they will ensure this situation will not happen again. This is potential risk to health safety of 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.
SUPERVISORS NAME: Martha Malane
LICENSING EVALUATOR NAME: Anna Francesca Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6