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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 300606476
Report Date: 05/07/2025
Date Signed: 05/07/2025 02:09:27 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-20250228133855
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:16CENSUS: 14DATE:
05/07/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Director Cynthia EstepTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Buildings and Grounds (Safety)
Fixtures, Furniture, Equipment and Supplies (Cabinet)
INVESTIGATION FINDINGS:
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On 05/07/2025, at 9AM 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 4 staff and 14 infant children.

The Department received a complaint on 2/28/2025 alleging (1) Facility staff do not ensure play area used by infant children is safe and in good condition (2) Staff are not maintaining soft cushioning for the play area.

Based on LPA’s observations, the metal base of the pole that holds the shade was broken and the broken part, which is accessible to children, was sharp and rusty. Staff stated the pole broke during high winds in February and the school planned on replacing them.

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 5
Control Number 06-CC-20250228133855
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: 300606476
VISIT DATE: 05/07/2025
NARRATIVE
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Based on LPA’s observations, the cushioning material in the infant playground is pour in place rubber. The rubber surface was covered with a plastic straw mat. LPA observed the edges of the mat were curling up and may be a tripping hazard. Staff stated they used the mat temporarily to prevent children from scratching their knees when they fall. LPA observed the surface has developed cracks and the surface was rough to the touch.

None of the parents interviewed disclosed any information that supported the allegation.

Children were not interviewed due to age and being non-verbal.

Based on observations and interviews conducted the preponderance of evidence standard has been met therefore the allegations are SUBSTANTIATED. A substantiated finding means the allegations were valid because the preponderance of the evidence standard has been met. See LIC9099D for 2 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)

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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 5
Control Number 06-CC-20250228133855
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: 300606476
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(a)
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101238 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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Director stated the facility has planned to cement the broken base to cover the hole.
Director stated they will send plan of action to address the issue and will send a written plan and action taken to LPA by due date of 6/9/25
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Based on observation and interview, the metal base of the pole that holds the shade was broken and the broken part, which is accessible to children, was sharp and rusty.
This poses a potential risk to health and safety of children in care
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Type B
06/09/2025
Section Cited
CCR
101238.2(e)
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101238.2 Outdoor Activity Space
(e) As a condition of licensure, the areas around and under high climbing equipment, swings, slides and other similar equipment shall be cushioned with material that absorbs falls.
This requirement was not met as evidenced by
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During delivery of complaint, the mats in the infant yard has flatten out. Director stated they will regularly inspect the mat and replace when necessary. A document stating that action will be sent to LPA by due date.
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 LPA observed the edges of the mat were curling up and may be a tripping hazard. Based on interview, the mat was temporarily placed to prevent children from scrstching their legs on the original cushioning which was rough to touch
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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 5
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-20250228133855

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:16CENSUS: 14DATE:
05/07/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Director Cynthia EstepTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Director Qualifications
Ratio
Staff Qualifications
Buildings and Grounds (Shade)
Fixtures, Furniture, Equipment and Supplies (Cabinet)
Daily Inspection for Illness
INVESTIGATION FINDINGS:
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On 5/7/2025, at 9AM 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 4 staff and 14 infant 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) Facility staff do not ensure facility furniture are properly secured, (6) Staff did not ensure infectious disease is managed.

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 5
Control Number 06-CC-20250228133855
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: 300606476
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. Based on observation, the facility is operating within its licensed capacity and staffing ratios (3) Staff interviewed stated they have not witnessed 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 infant yard which is provided by the wood pergola structure. (5) the metal cabinet in the yard is sturdy and safe. (6) Based on record review of ouch reports, there were no infant children who acquired infectious disease in the week of 2/21/25.

None of the parents interviewed disclosed any information that supported the allegation.

Children were not interviewed due to age and being non-verbal.

Based on observations, 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)
Page 2 of 2
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 5