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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304310224
Report Date: 08/16/2023
Date Signed: 08/16/2023 10:23:33 AM

Document Has Been Signed on 08/16/2023 10:23 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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:KELLY, TATIANAFACILITY NUMBER:
304310224
ADMINISTRATOR:KELLY, TATIANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 337-8394
CITY:LAHABRASTATE: CAZIP CODE:
90631
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 4DATE:
08/16/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensee, Tatiana KellyTIME COMPLETED:
10:30 AM
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On 08/16/23, Licensing Program Analyst (LPA) Dianna Valdez Santana conducted an unannounced case management visit to investigate an Unusual Incident Report (UIR) which was self-reported to the Regional Office on 08/09/23. LPA was met by licensee, Tatiana Kelly. During today's inspection, LPA and licensee, Tatiana toured the facility and census was taken: 3 preschool age children and 1 infant in care. Present at the time was licensee and her spouse. A review of staff criminal clearance records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

According to the self-reported incident, on 08/08/23, at around 7:45am 18-month-old Child #1 (C1) pulled a plug while licensee was opening the door so a child could enter the daycare room. Licensee stated she had a HEPA air purifier plugged into the wall; it was sitting on a shelf next to a child sized chair. There was a small gap between the wall and the chair, enough where C1 was able to pull on the cord. When Licensee was opening the door, her back was to C1 and she heard a loud “pop” and turned and saw a spark. She immediately removed C1 from the area, inspected C1 and she saw C1's pants and shirt had burn marks. She removed C1's clothes to check for injuries. She saw C1's right forearm was red/burned and C1's stomach had a red mark. Licensee stated she then applied burn cream and then immediately called C1’s Mother and notified the other parents as well. C1’s Parent arrived within 30 minutes and took C1 to the doctor to get treated. Licensee said C1’s Mother followed up and told her C1 had 2nd degree burns on the forearm. There were 7 children present at the time of the incident. Licensee talked to the children about staying safe around outlets.


Licensee stated she had her spouse immediately change all the outlets in the daycare room to “AFCI/ARC” protection outlets. C1 returned to the daycare on 8/14/23. Due to the information that was obtained by Licensee Tatiana Kelly, no citation is being issued. Exit interview was conducted with licensee. The Notice of Site Visit was posted. Facility representative was informed that the Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100. The Licensee was provided a copy of their appeal rights and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Licensing office within 15 business days. End of Report.
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Dianna ValdezSantana
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2023
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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