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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304370087
Report Date: 03/14/2022
Date Signed: 03/14/2022 06:23:16 PM

Document Has Been Signed on 03/14/2022 06:23 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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:PLACENTIA HEAD STARTFACILITY NUMBER:
304370087
ADMINISTRATOR:SMITH, KIMFACILITY TYPE:
850
ADDRESS:840 SOUTH MELROSETELEPHONE:
(714) 632-8787
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY: 80TOTAL ENROLLED CHILDREN: 80CENSUS: 32DATE:
03/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator Mr. Smith Kim TIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA), Desai, Ketki conducted an on site inspection for the purpose of a Required one year Annual inspection and a change of capacity (Decreasing from 80 preschool children to 60 Preschool age children in the assigned four classrooms. Facility is also removing one classroom from the Preschool age license.
LPA and Director Ms. Smith, Kim toured the facility inside and outside and the floor and yard plan (LIC 999) were verified. Census was taken in individual classrooms. The overall census observed was 6 preschool staff and 32 preschool children.
Due to COVID 19 guidelines, LPA observed staff and children wearing face mask, social distancing and following CDC and Dept of Public Health Guidelines.
During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staffing ratios. Facility hours are 7:30 AM.- 5:30 PM., Monday through Friday.
A review of the Facility Personnel Report Summary on this date indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

During the inspection of the indoor activity space, items which could pose a danger to children (detergents, cleaning compounds, and medications) were observed to be stored out of the reach of children. Poisons/Hazardous Items are stored in the Janitor's closet on the premises. Food is prepared on site; lunch and snacks are provided. Food prep areas were clean and sanitary. Food is properly stored. Menus were posted where they could be reviewed by parents.

Floors, equipment, and furniture were clean and were observed to be in good repair and free of sharp edges. There is drinking water available to children indoors by Brita water pitchers with small cups. The children's bathrooms are clean and sanitary. Each classroom has two age appropriate toilets and sinks inside the classrooms. (1)
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2022
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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: PLACENTIA HEAD START
FACILITY NUMBER: 304370087
VISIT DATE: 03/14/2022
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Children nap on cots and bedding is stored individually and linens and blankets are provided by the facility and are washed on the premises . The facility has conducted an emergency drill within the past six months. The facility has a working carbon monoxide detector and fire extinguisher. Facility met all posting requirement. The California Child Passenger Safety Law was posted by the entrance of the facility.

Staff files were reviewed for staff present during the facility inspection on this date, 6 out of 2 staff files were reviewed. Health screening and immunization's as required were reviewed. Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, 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. Proof of immunization against pertussis, measles for (licensee and assistant) were reviewed and within compliance. Beginning March 31, 2018, H&S Code 1596.8662 requires all directors and employees to complete mandated reporting training, and to renew the training every two years. At least one staff member present possesses current EMSA approved Pediatric CPR/First Aid certifications which expires October 6th 2022.

The Director Ms. Smith, Kim was informed that the Criminal Record Statement (LIC 508) has been
updated, and the facility must now use the new form with revised date 7/15. Director was also informed that the LIC 508 must be submitted with all Criminal Background Clearance and transfer request forms.

Children's records were reviewed, and there was a separate, complete and current record for each child. A random sample of (6) of children's files were reviewed for documentation of the child’s name, address, and telephone number of the child’s authorized representative and of relatives or others that can assume responsibility for the child if the authorized representative cannot be reached when necessary (LIC 700) and a medical assessment.In the areas reviewed the children’s files were found to be in full compliance. Sign in/out procedure was reviewed for compliance. The person who signs the child in and out uses their full legal signature and records the time of the day.

The outdoor activity space was inspected for compliance. The playground was enclosed by a fence at least four feet in height.The surface of the outdoor activity space was well maintained and free of hazards. The cushioning material soft cushion around the climbing equipment, and other similar equipment appeared to be enough to absorbs falls. Drinking water in the outdoor activity space is provided by water pitchers and cups.
The outdoor equipment and toys were in good repair and free of sharp edges. There are no bodies of water present at the facility. The facility grounds were safe, sanitary and in good repair. (2)
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022
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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: PLACENTIA HEAD START
FACILITY NUMBER: 304370087
VISIT DATE: 03/14/2022
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LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian
Information on the additional nutrition training, immunization requirements for children, and Health Schools Act (http://www.cdpr.ca.gov/docs/pestmgt/schoolipm.htm) were provided. The Director was informed, and website given, about the California Child Care Disaster Plan has been posted to the UCSF California Childcare Health Program website: cchp.ucsf.edu/content/disaster-preparedness Also provided was information about the E-Learning Modules available at https://ccld.childcarevideos.org A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the facility representative. Facility Director is in process of completing lead poisoning training.

Both Indoor and Outdoor areas were measured on today's inspection. As facility is decreasing their Preschool capacity by removing one room .

Indoor activity space: 2533.75 divided by 35 = 72.39 ( 72 children)

Outdoor activity space: 4346.50 divided 75 = 57.95 (60 children)

Total sinks and Toilets : each of the three classrooms has three sinks and 2 toilets inside the room
Sinks: 9 X 15 = 135 and Toilets : 6 X 15= 90.

Based on the indoor /outdoor measurements/ Sinks and Toilets availability: this facility has sufficient space to accommodate the requested capacity of 60 preschool age children (2-5 years old in the three designated classrooms.)
Criminal Record Statement : Facility Director Ms. Smith, Kim was reminded that all adults 18 and over responsible for administration or direct supervision of staff, persons who provides care and supervision to children, and staff who have contact with children, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022
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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: PLACENTIA HEAD START
FACILITY NUMBER: 304370087
VISIT DATE: 03/14/2022
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Safe Sleep : LPA discussed the safe sleep regulations with Facility Director Ms. Smith, Kim & 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 [applicant, licensee, or 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.

Incidental Medical Services: LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. 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: http://www.ada.gov/childqanda.htm

Exit Interview

Exit interview conducted and report was reviewed with the Director Ms. Smith, Kim

Review of records to be maintained : LPA reviewed with applicant, the LIC 311A, Records To Be Maintained At The Facility, for child’s records, personnel records, administrative records, and documents to be posted.

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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022
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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: PLACENTIA HEAD START
FACILITY NUMBER: 304370087
VISIT DATE: 03/14/2022
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A new license for a capacity of 60 Preschool age children (2-5 years) Monday to Friday 7:30 am to 5:30 pm in three designated rooms (Room # 2/ 3 and 4) shall be issued upon Management approval.

An Inspection and exit interview was completed with Facility Director Ms. Smith, Kim. The report was reviewed and discussed. Appeal Rights and deficiencies were discussed. The facility representative was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. If the facility receives a Type A violation, the licensee shall post and provide copies of the report to parents/guardians of the children in care at the facility by the next business day, and shall provide to the parents/guardians of children newly enrolled at the facility during the next 12 months. In addition, the licensee shall immediately post upon receipt the Proof of Correction for 30 consecutive days and provide a copy to current and enrolling parents. The licensee is to keep Acknowledgement Receipt (LIC 9224) signed by parents in each child’s file. Failure to post Type A reports for 30 days will result in a Civil Penalty of $100.00

The facility representative was informed that the “Notice of Site Visit” must be posted for 30 consecutive days. The “Notice of Site Visit” must be posted on or adjacent to the door. Failure to post will result in Civil Penalties of $100.00.
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022
LIC809 (FAS) - (06/04)
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