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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304270967
Report Date: 02/10/2025
Date Signed: 02/10/2025 11:45:03 AM

Document Has Been Signed on 02/10/2025 11:45 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:KATHARINE IRVINE DAY SCHOOL HEAD STARTFACILITY NUMBER:
304270967
ADMINISTRATOR/
DIRECTOR:
ROSA DOMINGUEZFACILITY TYPE:
850
ADDRESS:1002 WEST 2ND STREETTELEPHONE:
(714) 541-8164
CITY:SANTA ANASTATE: CAZIP CODE:
92701
CAPACITY: 64TOTAL ENROLLED CHILDREN: 64CENSUS: 21DATE:
02/10/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Rosa DominguezTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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On 2/10/2025, Licensing Program Analysts (LPA) Silva and Deschampe conducted a Case Management – Incident to investigate a incident dated 1/31/2025 involving Child #1. Upon arrival, the LPAs met with Director Rosa Dominguez. An on-site Facility Personnel Report Summary review indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Census was 37 children supervised by nine staff in four classrooms (Room 1 had 6 children, Room 2 had 12, Room 3 had 7, and Room 4 had 12). The facility was operating within ratios and capacity.

During the visit, the LPAs interviewed four staff, C1, and P1. S1 stated The child was climbing the leaf ladder and slipped from it in between the structure and the ladder. S1 did not actually see the incident. There was a lot of blood, so they called 911. S2 was in the playground closest to C1 when the incident happened. S2 did not actually see the incident happen but deduced the child was climbing the leaf ladder and missed a step, which resulted in a head injury. S3 stated they accompanied C1 to the hospital during the ambulance ride. According to S3, the child was alert during the ride. S4 provided a similar account as S1 and stated they observed the child climbing the leaf ladder in between the structure and the ladder. Per S4, C1 missed a step and fell hitting the structure with their head.

The LPAs inspected the playground during the visit. The playground is appropriate for the ages served. There is cushioning material under the climbing equipment. The LPAs inspected C1’s injury. The injury is about 1 cm in length and the area around it is tender. The injury appears to be healing. The LPA observed a CHOC certificate dated 1/31/25 stating C1 can return to school with no limitations.

No violations of Title 22 CCR were observed during the inspection.

An exit interview was conducted and appeal rights and a notice of site visit were provided to the licensee. A signature on this report acknowledges receipt of these documents. The notice of site visit is to posted for 30 days.

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Archibaldo Silva
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2025
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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