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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304370197
Report Date: 09/28/2021
Date Signed: 09/28/2021 11:38:25 AM

Document Has Been Signed on 09/28/2021 11:38 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:GARDEN GROVE UNIFIED SCHOOL DISTRICT/PETERSFACILITY NUMBER:
304370197
ADMINISTRATOR:KYLE BENHAMFACILITY TYPE:
850
ADDRESS:13162 NEWHOPE STREETTELEPHONE:
(714) 663-6085
CITY:GARDEN GROVESTATE: CAZIP CODE:
92843
CAPACITY: 48TOTAL ENROLLED CHILDREN: 0CENSUS: DATE:
09/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Director of preschool program Emma Druitt TIME COMPLETED:
11:25 AM
NARRATIVE
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Licensing Program Analyst (LPA), Tina Nguyen conducted an onsite inspection for the purpose of a Required - 1 Year. LPA Nguyen meet with elementary secretary Cherryl Jacot, Director of preschool program Emma Druitt and Preschool teacher on specialist assignment Sabrina Bayle came after. LPA Nguyen and Director of preschool program Emma Druitt 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 5 preschool staff and 21 preschool children. During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staffing ratios. Facility hours are 8:15 am to 3 p.m., Monday through Friday. A review of the Facility Personnel Report Summary on this date indicates all facility staff 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 not kept on the premises. Breakfast/Lunch are provided by school District. 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 drinking fountain and cups. The children's bathrooms are clean and sanitary. 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, 3 staff files were reviewed. Health screening and immunizations as required were reviewed. (continue on page 2)
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Tina Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2021
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 4
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: GARDEN GROVE UNIFIED SCHOOL DISTRICT/PETERS
FACILITY NUMBER: 304370197
VISIT DATE: 09/28/2021
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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 08/2022. The facility representative 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. Facility representative was also informed that the LIC 508 must be submitted with all Criminal Background Clearance. Children's records were reviewed, and there was a separate, complete and current record for each child. 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.

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 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

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 rubber mats commercially produced for the purpose around the climbing equipment, slides and other similar equipment appeared to be enough to absorbs falls. Drinking water in the outdoor activity space is provided by drinking fountain and disposable cups.
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Tina Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: GARDEN GROVE UNIFIED SCHOOL DISTRICT/PETERS
FACILITY NUMBER: 304370197
VISIT DATE: 09/28/2021
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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.

Transfer Request (LIC9182). The facility representative was informed that Licensing Quarterly Updates are available at www.ccld.ca.gov facility representative may request to be added to an email list to receive a Quarterly Update by contacting the Child Care Advocate at childcareadvocatesprogram@dss.ca.gov or at www.ccld.ca.gov
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 (licensee / director/ facility representative) 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 does/does not have lead training Certificate.

A copy of the 2016 “A Child Care Providers Guild to Safe Sleep” was provided to the (licensee / director/ facility representative).
English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf
(IF SPANISH) Spanish: https//www.cdph.ca.gov/programs/SIDS/Documents/ChildCareProvSleepSPAN2011.pdf
AAP: https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx
NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Tina Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: GARDEN GROVE UNIFIED SCHOOL DISTRICT/PETERS
FACILITY NUMBER: 304370197
VISIT DATE: 09/28/2021
NARRATIVE
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Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials
· Always place infants on their backs for sleeping
· Use only a tight-fitting sheet on the crib or play yard mattress
· Do not hang any items from the crib or above the crib
· Keep all items, including blankets, out of the crib or play yard
· Pacifiers may be used as long as they do not have items attached to them
· Infants should not be swaddled or have any items covering them while sleeping
· The temperature of the room should be comfortable enough for an adult to wear a t-shirt and not be too hot or too cold
A copy of the Provider Information Notice (PIN) 20-06-CCP Social and Physical Distancing Guidance and Healthy practices for childcare facilities in response to the global coronavirus (COVID-19) pandemic written in collaboration with the CA Department of Education. A copy of COVID-19 posters and Essential workers list.

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.

An exit interview was completed with facility representative. The report was reviewed and discussed. The Notice of Site Visit was posted and discussed as required by H&S Code Sec. 1596.817. Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100.00. The Notice of Site Visit must be posted on or adjacent to the door.

Documents/Information to be updated and returned to the Licensing Office;
- Personnel Report (LIC 500)
- Emergency Disaster Plan (LIC 610)
- Designation of Administrative Responsibility (LIC 308)
- Fire Drill Log
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Tina Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
LIC809 (FAS) - (06/04)
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