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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304270714
Report Date: 10/05/2023
Date Signed: 10/05/2023 01:09:42 PM

Document Has Been Signed on 10/05/2023 01:09 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:EARLY CHILDHOOD CENTER OF TEMPLE BETH ELFACILITY NUMBER:
304270714
ADMINISTRATOR:NGUYEN, MELISSAFACILITY TYPE:
850
ADDRESS:2A LIBERTYTELEPHONE:
(949) 394-2070
CITY:ALISO VIEJOSTATE: CAZIP CODE:
92656
CAPACITY: 83TOTAL ENROLLED CHILDREN: 83CENSUS: 23DATE:
10/05/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:01 PM
MET WITH:Director Melissa NguyenTIME COMPLETED:
01:30 PM
NARRATIVE
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On 10/05/23 Licensing Program Analyst (LPA) Anna Chan conducted an unannounced Case Management – Deficiencies due to deficiencies observed during record reviews. Director Melissa Nguyen assisted the LPA during the visit. Census was taken and there are 23 children and 6 staff present during inspection.

The facility was operating within its licensed capacity and within compliance of staff-to-child ratios. A Personnel Report Summary review showed that all facility residents, staff, or other individuals who require background checks have received criminal record and child abuse index clearances or exemptions.

Based on observation and record reviews, the Sign In/Out sheet was not properly signed by child’s authorized representative. The sign in and out sheet does not show the representative’s full legal signature. The facility was not in compliance and in violations of the California Code of Regulations, Title 22, Division 6 Section 101229.1 (a)(1)Sign In and Sign Out. Deficiencies were observed, discussed, and cited at the time of the visit. The following violations of the CCR were cited in the attached 809D:

The LPA conducted an exit interview and reviewed the report with the licensee. The Notice of Site Visit was posted. The licensee understands that the Notice of Site Visit shall remain posted for 30 days. The Appeal Rights were explained. The licensee received a copy of the Appeal Rights (LIC 9058 01/16), their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. First-level appeals should be sent to the Regional Manager at the address listed above.

End of Report.

SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Anna Francesca Chan
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2

Created By: Anna Francesca Chan On 10/05/2023 at 11:50 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: EARLY CHILDHOOD CENTER OF TEMPLE BETH EL
FACILITY NUMBER: 304270714

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/06/2023
Section Cited
CCR
101229.1(a)(1)

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101229.1 (a) In addition to the sign-in procedure requirement...
(1) The person who signs the child in/out shall use his/her full legal signature and shall record the time of day.

This requirement is not met as evidenced by:
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Director stated they will start implementing a new procedure and send a note out to parents which will have the children's representative sign their full legal name in the sign in and out sheet. Director also stateed facility will try to do electronic sign in and out. A copy of the sign in and out sheet will be sent to LPA via text or email by due date of 11/06/23
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Based on record review, the facility sign in and out sheet is not correctly signed by the child's authorized representatived. The sign in and out sheet does not show full legal signature.
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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:Anna Francesca Chan
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023


LIC809 (FAS) - (06/04)
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