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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304270866
Report Date: 07/07/2023
Date Signed: 07/07/2023 01:15:15 PM

Document Has Been Signed on 07/07/2023 01:15 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 CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:SALVATION ARMY, TUSTIN RANCH-CREATOR'S CORNER, THEFACILITY NUMBER:
304270866
ADMINISTRATOR:MITCHELL, CHRISTINEFACILITY TYPE:
850
ADDRESS:10200 PIONEER ROADTELEPHONE:
(714) 210-6041
CITY:TUSTINSTATE: CAZIP CODE:
92782
CAPACITY: 112TOTAL ENROLLED CHILDREN: 112CENSUS: 21DATE:
07/07/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:07 AM
MET WITH:Director Christine MitchellTIME COMPLETED:
01:40 PM
NARRATIVE
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On 07/07/2023, A case management inspection incident was conducted by Licensing Program Analyst (LPA), Anna Chan who met with the Director, Christine Mitchell. Upon arrival at the facility, census was taken, there are 7 staff present and 21 children in care.

A review of criminal record clearances indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

On 06/28/2023 a self reported incident was received at the Regional Office. It was reported that on 06/27/2023, during a snack rotation, child #1 (C1) was given milk as part of the snack. C1 has a known milk allergy.

During investigation, LPA interviewed Staff # 2 (S2). S2 stated that C1 was given her own snack from home. When C1 was walking up after finishing a snack, Adult #1 (A1) was walking and giving cup made of styro foam with drinks to the children. S2 stated she was looking at C1 sipping on the cup, and when C1 placed the cup down the table, S2 noticed it was milk on the cup. S2 immediately took away the cup and rushed C1 to the admin office for observation. C1 has a known milk allergy that A1 was not made aware of. During the interview with Staff# 1 (S1), S1 stated, there was no outward sign of allergic reaction on C1. C1’s parent #1 (P1) was notified right away and P1 advised to administer Benadryl. C1 was given Benadryl, but C1 gagged and vomited the medicine and the snack she ate prior. P1 arrived at the facility aprrox 10 minutes later, and administered epi-pen. 15 minutes after epi-pen was administered, C1 developed hives all over the body. Facility called 911 and C1 was transported to the hospital. C1’s breathing and oxygen was fine according to the doctor. C1 returned to school on 06/29/2023.

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SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Anna Francesca Chan
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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 CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: SALVATION ARMY, TUSTIN RANCH-CREATOR'S CORNER, THE
FACILITY NUMBER: 304270866
VISIT DATE: 07/07/2023
NARRATIVE
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Based on the information gathered from the interviews conducted and record reviews, it was determined that C1 was violated for food service.

On 06/28/2023, a second self reported incident by the facility was received by the regional office. On 06/27/2023, C2 was seen unsupervised by Adult #2 (A2) in the toddler playground and notified S1. C2 was seen by S1 standing close to the locked gate of the toddler playground approximately 9 minutes later.

During this inspection, LPA interviewed S1, S3 and S4 who is present at the time of the incident. LPA obtained a copy of the children roster, for week of 06/26/2023 and Personnel Summary Report.

Based on LPA’s interview with S1, A VBS Program (Vacation Bible School) on 06/27/2023 started, an outdoor activity bounce house was placed in front of the fellowship hall. Staff #3 (S3) was going for a break. S3 stated she made sure staffing and ratio is covered and communicated with the other staff present. S3 was with C2 before taking a break. S3 stated that C2 did not want to participate in the bounce house play rotation. S3 transitioned C2 and made sure C2 walked to S4. S3 then walked through the back path of the facility through the black gate on the right side facing the fellowship hall, the gate was not closed and had a brick at the bottom of the gate to keep it open. The alley going to the break room is about 200 feet from where the outdoor activity is. Before entering the break room, S3 made sure no children were walking behind her.

On another interview with S4, S4 stated C2 wanted the snack she was distributing and asked for some and then went to the bounce house. S4 then announced to the children to start picking up their shoes. When the children were done picking up their shoes, S4 found C2's shoes and C2 was not present. S4 and Staff #5 (S5) started looking for C2 around the bounce house. When S4 and S5 did not find C2, the other staff in the area and in the admin office were notified about the incident and started looking everywhere. S1 was notified by A2 that C2 was spotted in the toddler playground. When S1 arrived at the toddler play area, C2 was alone standing by the gate which is enclosed and is locked with a security alarm.

Based on the information gathered from the interviews conducted, it was determined that C2 was left unsupervised and the whole incident happened for approximately 9 minutes.

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SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Anna Francesca Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023
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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 CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: SALVATION ARMY, TUSTIN RANCH-CREATOR'S CORNER, THE
FACILITY NUMBER: 304270866
VISIT DATE: 07/07/2023
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The facility was not in compliance of the California Code of Regulations, Title 22, Division 12. The following citations Food Service 101227(7)(B), and 101229(a)(1) Responsibility for Providing Care and Supervision is being cited on the attached 809D, and an immediate civil penalty was assessed. 101229(a)(1) is a repeat violation which was previously cited on 05/16/2023.

LPA Chan informed director Christine Mitchell that this report dated 07/07/2023 for Type A citation which shall be posted for 30 consecutive days as there is immediate risk to the health, safety, or personal rights of children in care.

LPA Chan informed the director Christine Mitchell to provide a copy of this licensing report dated 07/07/2023 Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Exit interview conducted and report was reviewed with the Director Christine Mitchell. A notice of site visit was given and must remain posted for 30 days. Failure to post will result in civil penalties of $100.



Appeal Rights and deficiencies were discussed. The facility representative was provided a copy of their appeal rights (LIC 9058) and 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 to the address listed above.

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End of Report
SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Anna Francesca Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/07/2023 01:15 PM - It Cannot Be Edited


Created By: Anna Francesca Chan On 07/07/2023 at 12:08 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: SALVATION ARMY, TUSTIN RANCH-CREATOR'S CORNER, THE
FACILITY NUMBER: 304270866

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/10/2023
Section Cited
CCR
101227(7)(B)

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101227(7)(B) Food Service
(7) Modified diets prescribed by a child's physician...(B) A child shall not be served any food to which the child's record indicates he/she has an allergy.

This requirement is not met evidenced by:
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Director stated that they had an emergency staff meeting on 6/30/23 to review policies and procedure for allergies. First aid and administering epi-pen was reviewed and discussed. All children with known allergies were given a red bracelet to wear for the remainder of the VBS.
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Based on LPA’s interview and record review, the facility served an allergic item (milk) to Child #1 during snack time, and the Item was listed on Needs and Service Plan, Allergy list, and LIC 702 Child's Preadmission Health History-Parents Report which was received upon admission by the facility. This poses an immediate risk to Health and Safety to children in care.
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 A copy of the agenda with staff signatures acknowledging training was provided to the LPA during the visit, and POC was cleared the same day of the visit 7/7/23.
Type A
07/10/2023
Section Cited
CCR101229(a)(1)

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101229 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time.
This requirement is not met evidenced by:
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The director stated that they did an emergency staff meeting on 6/30/23 to review policies and procedure about supervision, safety and maintaining ratio. A copy of the agenda with staff signatures acknowledging the said meeting will be provided to LPA on 7/7/23
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Based on LPA’s interviews to 3 staff, C1 was unsupervised for 9 minutes. Staff were not aware that C1 left the play area and went to the toddler playground which is approx. 900 feet from the activity area.
This poses an immediate risk to health and safety to children in care
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Director stated that the facility will put up signs on the gate to keep close. Proof of signage will be sent to LPA via email or text by due date of 7/10/23

The same citation was issued on 5/16/23. A civil penalty was assessed for repeat violation.
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:Rina Lopez
LICENSING EVALUATOR NAME:Anna Francesca Chan
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023


LIC809 (FAS) - (06/04)
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