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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300606476
Report Date: 08/26/2022
Date Signed: 08/26/2022 03:29:54 PM

Document Has Been Signed on 08/26/2022 03:29 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:
300606476
ADMINISTRATOR:REBEKAH BAYFACILITY TYPE:
830
ADDRESS:12881 NEWPORT AVENUETELEPHONE:
(714) 544-4431
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY: 16TOTAL ENROLLED CHILDREN: 16CENSUS: 7DATE:
08/26/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Rebekah Bay - DirectorTIME COMPLETED:
04:00 PM
NARRATIVE
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An unannounced case management report was initiated on this date by Licensing Program Analyst (LPA) Odom based on information discovered during a complaint investigation initiated on 6/28/22.

Present today was Director Rebekah Bay, who greeted LPA upon arrival. During Facility Inspection LPA observed 7 infants and 5 staff.

In the course of the investigation it was discovered that Director did not report Hand, Food, Mouth disease outbreak that occurred in the toddler classroom to licensing office within 24 hours and in writing within 7 days. LPA asked Director the reason why the incident was not reported, Director stated, they were not aware they had to report the incident and Administration would handle reporting the incident. LPA Odom spoke with staff #2 if they reported the incident and they were not aware of the reporting requirement regulations. Therefore, facility is being cited.

California Code of Regulations, Title 22, Division 12, Chapter 1, Reporting Requirements 101212(d)(1)(E) d) Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, 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 report containing the information specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event. (1) Events reported shall include the following: (E) Epidemic outbreaks. is being cited on the attached LIC 809D

Exit interview was conducted. Notice of Site Visit was posted during the visit. Director 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. Director was provided a copy of their appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. First level appeals should be sent to the regional manager to the address listed above

SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Carmen Odom
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2022
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 08/26/2022 03:29 PM - It Cannot Be Edited


Created By: Carmen Odom On 08/26/2022 at 01:28 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: 300606476

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/26/2022
Section Cited
CCR
101212(d)(1)(C)

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Reporting Requirements 101212(d)(1)(C ): (d)(1) below, a report shall be made to the Dept by telephone… within the Department's next working day and during its normal business hours. In addition, a written report containing the information…within seven days following occurrence… (1)... This requirement was not met as evidenced by:
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Director stated they will make sure they report unusual incident with 24 hour and in writing within 7 days. Director will submit the LIC624 UIR for the Hand, Foot, Mouth diseases cases in the toddler room.
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Based on observations and interviews Director did not report the multiple cases of hand, foot, mouth disease that occurred in the infant center to licensing office or department of public health. This poses a potential risk to the health and safety 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:Judy Hanson
LICENSING EVALUATOR NAME:Carmen Odom
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2022


LIC809 (FAS) - (06/04)
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