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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304270947
Report Date: 01/22/2026
Date Signed: 01/22/2026 09:58:52 AM

Document Has Been Signed on 01/22/2026 09:58 AM - 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:CALVARY CHAPEL PACIFIC COAST-LITTLE LIGHT P/SFACILITY NUMBER:
304270947
ADMINISTRATOR/
DIRECTOR:		FLORES, HOPEFACILITY TYPE:
850
ADDRESS:6400 WESTMINSTER BLVD.TELEPHONE:
(714) 349-6933
CITY:WESTMINSTERSTATE: CAZIP CODE:
92683
CAPACITY: 120TOTAL ENROLLED CHILDREN: 99CENSUS: 34DATE:
01/22/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Facility Representative, Laura PowerTIME VISIT/
INSPECTION COMPLETED:
10:15 AM
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On 01/22/2026, Licensing Program Analyst (LPA) Deschampe conducted an unannounced visit to deliver findings in response to a self-reported Unusual Incident Report (UIR)(LIC 624) received on 09/05/2025 regarding inappropriate child on child interaction. This is a continuation of the investigation initiated on 09/15/2025. At 8:30 AM LPA was allowed entry to the facility and greeted by the facility director, Hope Flores. A walk through of the facility was conducted, with the following census: Total census was 34 preschool children and 11 staff. Total enrollment for the facility is 99 preschool children, with half-day, full-day, and non-regulated staggered schedules.

On 09/05/2025, an Unusual Incident Report was filed with the Orange County Regional Office (OCRO) by the facility director, Hope Flores to self-report an incident that allegedly occurred on 09/03/2025. Hope stated on 09/03/2025, Staff 3 (S3) observed both Child 1 (C1) and Child 2 (C2) were trying to pull each other’s pants down and told them to stop. When C1 was picked up by Parent 1 (P1), C1 told P1 that C2 pulled down C1’s pants and C2 stuck their finger in C1’s butt.

During the investigation, LPA made observations, interviewed 3 staff, attempted to interview 2 children, interviewed 2 parents/authorized representatives, obtained pertinent documentation including emails, children’s records, facility ouch reports, facility incident reports, and screenshots of text messages.

During the staff interviews, facility director, Staff 2 (S2), and Staff 3 (S3) stated they did not witness C2 pulled down C1’s pants and stick their finger in C1’s butt. S2 stated S2 did not witness the alleged incident. S3 stated S3 did not witness the alleged incident. However, S3 stated S3 believed C2 pulled down C1’s pants and stick their finger in C1’s butt because C2 is real rough with friends and C2 has had a lot of incidents pulling friends and pushing them. Facility director stated she believed C2 put fingers in C1’s butt

NAME OF LICENSING PROGRAM MANAGER: Thuy Ho
NAME OF LICENSING PROGRAM ANALYST: Susan Deschampe
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: CALVARY CHAPEL PACIFIC COAST-LITTLE LIGHT P/S
FACILITY NUMBER: 304270947
VISIT DATE: 01/22/2026
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because the day C1 claimed it happened, another teacher told the facility director that they witnessed C1’s behavior was noticeably different and abnormal. C1 normally would not want to go home when being picked up but on the alleged incident day, C1 told P1 that C1 was ready to go home when being picked up.

LPA attempted to interview C1 and C2 using the Ten Step Investigative Interview and both children did not qualify for an interview.

Based on LPA’s interviews, observation, and record review, there was adequate evidence to support C1’s disclosure. California Code of Regulations, Title 22 Division 12 Chapter 1, Section 101229 Responsibility for Providing Care and Supervision is being cited on the attached LIC 809D.

The exit interview was conducted with the facility representative, Laura Power. The Notice of Site Visit was posted during the visit. The facility representative was reminded that the Notice of Site Visit must be posted for 30 consecutive days. Appeal Rights were discussed and provided to the facility representative and their signature on this form acknowledges receipt of these rights. Licensee must file an appeal, in writing, to the Regional Manager within 15 business days from the date of receiving the penalty assessment or notice of deficiency. First level appeals should be sent to the Regional Manager at the address listed above.

End of report

NAME OF LICENSING PROGRAM MANAGER: Thuy Ho
NAME OF LICENSING PROGRAM ANALYST: Susan Deschampe
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/22/2026 09:58 AM - It Cannot Be Edited


Created By: Susan Deschampe On 01/22/2026 at 09:04 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: CALVARY CHAPEL PACIFIC COAST-LITTLE LIGHT P/S
FACILITY NUMBER: 304270947

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/19/2026
Section Cited
CCR
101229(a)(1)

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101229(a)(1)...No child(ren) shall be left without the supervision of a teacher at any time...shall include visual observation.

This requirement is not met as evidenced by:
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Facility will add additional support staff to ensure visual observation at all times.
Facility will make staff schedule adjustments to accommodate the needs of the classroom.
In-service with staff to review regulation, name-to-face, headcount protocol, line-up protocol.
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Based on staff interview, 2 out of 3 staff stated they believe C2 put fingers in C1’s butt even though they did not witness it. This poses a potential risk to the health of 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.
Thuy Ho
NAME OF LICENSING PROGRAM MANAGER:
Susan Deschampe
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2026


LIC809 (FAS) - (06/04)
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