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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304300460
Report Date: 06/19/2025
Date Signed: 06/19/2025 04:11:18 PM

Document Has Been Signed on 06/19/2025 04:11 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:URBINA, JESSIE & IRELIFACILITY NUMBER:
304300460
ADMINISTRATOR/
DIRECTOR:		URBINA, JESSIE & IRELIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 229-4847
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 1DATE:
06/19/2025
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Urbina, Jessie and Ireli (Licensees) TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On 6/19/2025, an unannounced inspection was conducted at the facility by Licensing Program Analyst (LPA) V. Trinh. At 2:00PM observed licensees with one child. Licensee was operating within the licensed capacity as specified on license. A review of the Facility Personnel Report Summary on this date 6/19/2025 indicates all facility residents, staff, or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

Licensees was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated. Currently, there are two (2) adults, including the licensee, and three (3) minor children living in the facility. Facility Day care hours are 6:00am-6:00pm, Monday through Friday.

During today’s inspection, LPA and licensees toured the inside and outside areas of the facility sketch LIC 999 as accessible to childcare children. This is a single home, with 4 bedrooms and 2 1/2 bathrooms, garage, front yard with fence, backyard with (fence/wall).

Off-limits areas are made inaccessible by means latches, and baby gate. Licensee stated that OFF LIMITS areas include: All three (4) Bedrooms, Work Office, Garage, Back Yard, Both of the Side Yard, kitchen, and Storages. The licensee acknowledged that children may never enter these off-limit areas

INDOOR INSPECTION: The childcare area consists of the Living room, Family room, and Front Yard. During inspection, the Children’s restrooms located in the hallway and inside the family room.

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NAME OF LICENSING PROGRAM MANAGER: Nguyen K Tran
NAME OF LICENSING PROGRAM ANALYST: Vivian Trinh
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2025
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 5
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: URBINA, JESSIE & IRELI
FACILITY NUMBER: 304300460
VISIT DATE: 06/19/2025
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OUTDOOR INSPECTION: The playground was enclosed by a fence. The outdoor equipment and toys were in good repair and free of sharp edges. At the time of inspection, the surface of the outdoor activity area was well maintained and free of any observable hazards. Children will be able to have outside play in the enclosed front yard. There were no bodies of water, and pets in the facility at the time of inspection.

The children do not use the backyard.

Garage will not be used for day-care. The Licensees stated the garage will be off-limit.

Garage is to be utilized for limited activities, day-care children are not to napped or eat in the Garage.

There are working carbon monoxide, smoke detectors, that should be type 2A-10BC, and fire extinguishers in the home that meet statutory and State Fire Marshall standards. Detergents, cleaning compounds, medicines, and other items which could pose a danger if readily available to children were stored inaccessible to children. There were no poisons or other items observed which could pose a danger to children or if they were observed, they were locked or inaccessible. Licensee stated there is no firearms dangerous weapons in the facility. LPA recommended that the ammunition shall be stored and locked separately from firearms.

There is a fireplace and an open-faced heater in the living room screened by a glass cover, which is barricaded by a cemented wall, and inaccessible to children in care. The home has age-appropriate toys for the ages served. During today’s inspection LPA observed. The Licensee is aware that each FCCH shall conduct fire drills and disaster drills at least once every six months. Fire drill was conduct on 6/2/2025. LPA verified there is a working telephone service (cellular service), licensee was reminded that childcare phone needs to remain the in the childcare at all times.

The licensees Pediatric CPR/First Aid certification expired 9/2026. Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a family childcare home if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles for were reviewed and within compliance. Beginning March 31, 2018, H&S Code 1596.8662 requires all licensed providers and employees to complete mandated reporting training and to renew the training every two years.

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NAME OF LICENSING PROGRAM MANAGER: Nguyen K Tran
NAME OF LICENSING PROGRAM ANALYST: Vivian Trinh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
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: URBINA, JESSIE & IRELI
FACILITY NUMBER: 304300460
VISIT DATE: 06/19/2025
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This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514- 0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-carecenters/

The licensees understands they must be present in the facility and must ensure children in care are always supervised. Children are not to be left alone in parked vehicles. When the licensees are temporarily absent from the facility, arrangements must be made for a qualified substitute adult to care and supervise children while absent. The substitute adult must have the required criminal record, child abuse index clearances, immunizations, Pediatric CPR/First Aid, and mandated reporter training. LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian

CCLD website www.cdss.ca.gov/inforesources/community-care-licensing was provided to licensee to access regulations, updates, and licensing forms. Licensee was advised to register through childcareadvocatesprogram@dss.ca.gov in order to receive quarterly updates. Licensee was advised of their responsibility to review the Provider Information Notices (PIN) found on the CCLD website. A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the licensees.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee [facility representative] of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.


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NAME OF LICENSING PROGRAM MANAGER: Nguyen K Tran
NAME OF LICENSING PROGRAM ANALYST: Vivian Trinh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: URBINA, JESSIE & IRELI
FACILITY NUMBER: 304300460
VISIT DATE: 06/19/2025
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LPA discussed Assembly Bill 2866 regarding in-ground swimming pool safety requirement and provided licensee PIN 25-01-CCP Chaptered Legislation Affecting Childcare Facilities.

Licensees was informed of the MyChildCarePlan.org website, a consumer education website that helps families obtain child care by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

In the areas that were evaluated, NO deficiencies were observed of the California Code of Regulations, Title 22, Division 12 at the time of the visit.

Exit interview conducted and report was reviewed with the licensee Urbina, Ireli. A notice of site visit was given and must remain posted for 30 days.

During the exit interview, the licensee, Urbina, Ireli, confirmed that there are no Registered Sex
Offenders living in the facility and LPA completed the RSO profile in FAS.

End of the Report.
NAME OF LICENSING PROGRAM MANAGER: Nguyen K Tran
NAME OF LICENSING PROGRAM ANALYST: Vivian Trinh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
LIC809 (FAS) - (06/04)
Page: 5 of 5