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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304370249
Report Date: 08/22/2024
Date Signed: 08/22/2024 01:04:04 PM

Document Has Been Signed on 08/22/2024 01:04 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:COUNTRY VILLAGE PRESCHOOL R.S.M.FACILITY NUMBER:
304370249
ADMINISTRATOR/
DIRECTOR:		SUTTER, MARISAFACILITY TYPE:
850
ADDRESS:21931 AVENIDA DE LOS FUNDADORETELEPHONE:
(949) 858-0999
CITY:RANCHO STA MARGAITASTATE: CAZIP CODE:
92688
CAPACITY: 120TOTAL ENROLLED CHILDREN: 21CENSUS: 17DATE:
08/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Licensee-Marisa SutterTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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On 8/22/2024 Licensing Program Analyst (LPA) Karen Navar conducted an unannounced case management incident inspection in response to a self-report Unusual Incident dated 8/14/2024 and 8/15/2024. LPA met with Director Marisa Sutter and toured the facility. LPA observed 17 preschool age children along with 3 staff during playground time.

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.

On 8/14/2024 a self reported Unusual Incident Report (UIR) was filed with the Licensing Office. The facility reported on 8/13/2024, that a parent had reported to them that a child had inappropriately touched their child. On 8/15/2024 Staff 2 (S2) then followed up with an additional incident occurring during playground time.

On 8/22/2024 during tour, LPA observed 3 staff and 17 children transitioning from the playground to classroom time. LPA walked around playground and observed different standing points. LPA then observed classroom 4 with 1 staff and 5 children putting their belongings away.

During staff interview with Staff 2 (S2), they stated they did not witness or hear of the incident until it was reported to them on 8/13/2024. S2 stated that parent of C1 stated that they talked to C1 and that the inappropriate touch did happen to C2 and that C1 has stated the same story that was reported to me. S2 stated there are typically 2 staff members on the playground and that they rotate around the playground to provide supervision to children and during nap time there is 1-2 staff supervising children and that room 4 can have 12 children. S2 stated that they have spoken with staff regarding supervision guidelines since the incident has happened.

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SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Karen Navar
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2024
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: COUNTRY VILLAGE PRESCHOOL R.S.M.
FACILITY NUMBER: 304370249
VISIT DATE: 08/22/2024
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During staff interview with Staff 1 (S1), they stated that they did not hear of the inappropriate touch incident on the playground until the parent reported it to us. S1 stated on 8/13/2024 parent approached them and asked about the inappropriate touch that day and that they could not think of anything because they did not witness anything unusual. S1 stated when they thought back through the day the only incident that possibly it could have happened was at rest time. S2 stated they did witness C1 over next to C2 during rest time on 8/13/2024. S1 stated they went over to where C1 and C2 were and spoke with C1 to go back to their spot and did not see anything unusual and C1 or C2 did not disclose any information that can support the inappropriate touch incident.

In the areas that were evaluated, one Type A deficiency is being cited of the California Code of Regulations, Title 22, Division 12 at the time of the visit. California Code of Regulations, Title 22, Division & Chapter 12, is being cited on the attached LIC 9099 D for the deficiency sections 101229 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the children's needs (1) No child(ren) shall be left without the supervision of a teacher at any time. Supervision shall include visual observation. Based on interviews staff did not visually observe or witness C2 being inappropriately touched by C1. S2 stated that parent of C1 stated that C1 inappropriately touched C2.

LPA Navar informed Director Marisa Sutter that this report dated 8/22/2024 documents one Type A citation which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Navar informed the Director Marisa Suttler to provide a copy of this licensing report dated 8/22/2024 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Exit interview conducted and report was reviewed with the Director Marisa Sutter. Notice of site visit was given and must remain posted for 30 days. Failure to comply with the posting requirements shall result in an immediate civil penalty of $100. End of report.

SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Karen Navar
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/22/2024 01:04 PM - It Cannot Be Edited


Created By: Karen Navar On 08/22/2024 at 12:22 PM
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: COUNTRY VILLAGE PRESCHOOL R.S.M.
FACILITY NUMBER: 304370249

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/23/2024
Section Cited
CCR
101229(a)(1)

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101229(a)(1) Responsibility for Providing Care and Supervision (a)The licensee shall provide care and supervision as necessary.. (1)No child(ren) shall be left without the supervision of a teacher...Supervision shall include visual observation. This requirement is not met as evidenced by..
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Staff meeting-Review supervision with staff and provide signatures that it was reveiwed. A copy was provided to LPA on 8/22/2024.
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Based on interviews staff S1 and S2 did not visually observe or witness C2 being inappropriately touched by C1. S2 stated that parent of C1 stated that C1 inappropriately touched C2.
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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:Judy Hanson
LICENSING EVALUATOR NAME:Karen Navar
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2024


LIC809 (FAS) - (06/04)
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