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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304310878
Report Date: 09/17/2024
Date Signed: 09/19/2024 03:27:59 PM

Document Has Been Signed on 09/19/2024 03:27 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:DAVIS-HENDERSON, ANNASTASIAFACILITY NUMBER:
304310878
ADMINISTRATOR/
DIRECTOR:		DAVIS-HENDERSON,ANNASTASIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 510-4663
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
09/17/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:AssistantsTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
NARRATIVE
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An Annual Random inspection was conducted at the facility by Licensing Program Analyst (LPA) Mahnaz (Nancy) Malek. LPA met with licensee's assistants, Sophia Isales and Lauren Tamme. LPA also met with resident, Scott Henderson. The licensee, Annastasia Davis Anderson was not present. LPA observed 8 children of whom 4 were under 24 months old under supervision of two assistants. Licensee was operating within the licensed capacity as specified on license for Large Family Childcare Home.

A review of the Facility Personnel Report Summary on this date indicates all facility residents, staff, or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

According to the updated information received, currently there are three adults including the licensee, and no minors living in the house. Day care hours of operation is Monday through Friday from 8:00 am-5:00 pm.

During today’s inspection, LPA and toured the inside and outside areas identified in the facility sketch as accessible to childcare children. Off limits areas are made inaccessible by means of baby gates. The childcare area consists of family room, one bedroom, children's bathroom and backyard. . There is a door on the kitchen side and the children's area to make the kitchen inaccessible to children. There is a baby gate installed between the children's area and hallway entrance to make the hallway entrance inaccessible to I play structure with slides and 3 swings with enough cushioning under and around the falling zones. (wood-chips and turf) in the backyard.

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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE: DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2024
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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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: DAVIS-HENDERSON, ANNASTASIA
FACILITY NUMBER: 304310878
VISIT DATE: 09/17/2024
NARRATIVE
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There are age appropriate toys and equipment for children to play outside. There are 4 cribs available for infants. Older children nap on mats.
The garage is not for children's use and is inaccessible to children by the garage door being locked.

There are working carbon monoxide, smoke detector, 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 to children were not readily available to children they were stored inaccessible to children, none were observed during inspection.

According to adult resident, Scott Henderson, there is no firearm in the facility. There is one cat living in the outdoor space. LPA verified there is a working telephone service (cellular service).

The licensee does have a current roster of children in care. Fire Drill was available. The last fire drill was conducted 4/30/2024. Children’s records for children present during LPA’s inspection were reviewed. Eight files were reviewed. They were all in compliance. The log for every 15 minutes check on napping children under 24 months old were available. LIC 9227 (Individual Infant Sleeping Plan) for infants under 12 months old were available on their files. The assistants' CPR/First Aid certification are current. (Expires 3/12/2026).

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 adult # 1 and adult # 2 were not 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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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
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 CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: DAVIS-HENDERSON, ANNASTASIA
FACILITY NUMBER: 304310878
VISIT DATE: 09/17/2024
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Mandated Reporter Training Certificate for the licensee's assistants were current.

Incidental Medical Services (IMS) policy was discussed. For information see PIN 22-02-CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

The licensee 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 licensee is 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, immunization, Pediatric CPR/First Aid, and mandated reporter training.

Licensee's representative, Sophia Isales was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance before working 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.

LPA discussed the safe sleep regulations with Licensee's representative, Sophia Isales 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,

LPA also informed Licensee's representative, Sophia Isales of the importance of checking for recalled as infant devices on the United States Consumer Product Safety Commission (CPSC) website at: https://www.cpsc.gov/, and

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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
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 CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: DAVIS-HENDERSON, ANNASTASIA
FACILITY NUMBER: 304310878
VISIT DATE: 09/17/2024
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recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Licensee's representative, Sophia Isales was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California. Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms.

To receive important licensed related information to licensed facilities, visit the CCLD Important Information website athttps://www.cdss.ca.gov/inforesources/community-care- licensing/subscribe and select the Child Care option to receive email communication.

In the areas that were evaluated, the following deficiency was observed of the California Code of Regulations, Title 22, Division 12 on this inspection. Please see LIC 809D for details of deficiency.

A notice of site visit was given to Licensee's representative, Sophia Isales and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Failure to post will result in Civil Penalties of $100.00.

Exit interview conducted and report was reviewed with the Licensee's representative, Sophia Isales.

End of report

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/19/2024 03:28 PM - It Cannot Be Edited


Created By: Mahnaz Malek On 09/17/2024 at 10:35 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: DAVIS-HENDERSON, ANNASTASIA
FACILITY NUMBER: 304310878

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one count out of 2 counts missing MMR, and Pertussis, and Flu vaccines for Adults # 1 and 2 which poses a potential health, and safety risk to persons in care. Flu shot is optional and maybe declined by a written statement.
POC Due Date: 09/24/2024
Plan of Correction
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It was agreed that the proof of MMR, Pertussis, and Flu vaccines for Adult # 1 and 2 to be sent to LPA's email address by the due date of 9/24/2024
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Thuy Ho
LICENSING EVALUATOR NAME:Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024


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