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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304270045
Report Date: 01/14/2025
Date Signed: 01/14/2025 02:09:50 PM

Document Has Been Signed on 01/14/2025 02:09 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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:ABC DEVELOPMENT PRESCHOOL #4FACILITY NUMBER:
304270045
ADMINISTRATOR/
DIRECTOR:		BRZUSKA, NIKKIFACILITY TYPE:
850
ADDRESS:4440 SURREY AVE.TELEPHONE:
(714) 828-4222
CITY:CYPRESSSTATE: CAZIP CODE:
90630
CAPACITY: 60TOTAL ENROLLED CHILDREN: 60CENSUS: 25DATE:
01/14/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Operation Director, Kelly Santos TIME VISIT/
INSPECTION COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Patricia Duron conducted a case management investigation for the incident that the facility self-reported to licensing office on 1/06/2025. According to the incident report, the incident occurred on 1/02/25 at approximately 4:55 PM. The director reported, Child 1 (C1) was left unsupervised on the playground, C1 was hiding behind the play equipment.

LPA met with Operation Director and census was taken. LPA observed 5 staff with 25 preschool age children. A review of staff criminal clearance records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

During today's inspection LPA Duron reviewed files and interviewed 3 staff members.

Operation Director stated on 1/02/25, 2 staff members were outdoors with 9 children. S1 counted the children and S2 re-counted the children while they were outdoors. The children walked indoors towards the carpet area with S1. S1 counted the children as they walked in and counted only 8 children. S2 had already closed the door. S3 went to the backdoor and opened the door and saw C1 outside hiding behind the play equipment. S3 stated, C1 was laughing and smiling when S3 saw C1 outdoors.

During today's staff interviews , 3 out of 3 staff stated the incident regarding C1 left unsupervised outdoors was for approximately 3 to 4 seconds.

The operation director stated she counseled each staff member regarding the protocol to ensure supervision and counting children before and after transitions. The operation director stated she reminded one staff member to stand in the front of the line, as the other staff member stands at the end of the line to ensure supervision at all times.
SUPERVISORS NAME: Martha Malane
LICENSING EVALUATOR NAME: Patricia Duron
LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2025
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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: ABC DEVELOPMENT PRESCHOOL #4
FACILITY NUMBER: 304270045
VISIT DATE: 01/14/2025
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In the areas that were evaluated, one deficiency was cited of the California Code of Regulations, Title 22, Division 12 Chapter 1 Section 101229 Responsibility for Providing Care and Supervision (a)(1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation. Please refer to attached 9099D for documentation of deficiencies.

An exit interview was completed. Appeal Rights and deficiencies were discussed. A copy of the Appeal Rights was given to the facility representative. All appeals must be in writing and received by the Licensing office within 15 days.

THE FACILITY REPRESENTATIVE WAS INFORMED THAT THE NOTICE OF SITE VISIT MUST BE POSTED FOR 30 CONSECUTIVE DAYS. FAILURE TO POST WILL RESULT IN CIVIL PENALTIES OF $100.00. THE NOTICE OF SITE VISIT WAS POSTED ON THE DOOR.
SUPERVISORS NAME: Martha Malane
LICENSING EVALUATOR NAME: Patricia Duron
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/14/2025 02:09 PM - It Cannot Be Edited


Created By: Patricia Duron On 01/14/2025 at 11:41 AM
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: ABC DEVELOPMENT PRESCHOOL #4
FACILITY NUMBER: 304270045

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/14/2025
Section Cited
CCR
101229

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101229 Responsibility for Providing Care and Supervision (a)(1) No child(ren) shall be left without the supervision of a teacher at any time.... Supervision shall include visual observation.This requirement is not met as evidence by:
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Operation Director operation director stated she counseled each staff member regarding the protocol to ensure supervision and counting children before and after transitions, she reminded staff to have one staff member to stand in the front of the line, as the other staff member stands at the end of the line to ensure supervision at all times.
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Based on LPA’s interviews,3 out of 3 staff stated the incident regarding C1 left unsupervised outdoors was for approximately 3 to 4 seconds.This action poses a risk to the health and safety to 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:Martha Malane
LICENSING EVALUATOR NAME:Patricia Duron
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2025


LIC809 (FAS) - (06/04)
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