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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304370256
Report Date: 06/18/2025
Date Signed: 06/18/2025 03:33:10 PM

Document Has Been Signed on 06/18/2025 03:33 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:TUTOR TIME CHILD CARE/LEARNING CENTERFACILITY NUMBER:
304370256
ADMINISTRATOR/
DIRECTOR:		MARY JOY HILSABECKFACILITY TYPE:
850
ADDRESS:24291 AVILA ROADTELEPHONE:
(949) 831-8887
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY: 170TOTAL ENROLLED CHILDREN: 170CENSUS: 35DATE:
06/18/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:05 AM
MET WITH:DirectorTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA), Mahnaz (Nancy) Malek conducted an onsite inspection for the purpose of Annual/Random inspection. LPA met with director Mary Joy Hilsabeck. Census was taken. There was a total of 35 preschool children with 5 staff in 3 different rooms. TK room, Multi Purpose Room, and Village room were not in use. There wee 7 children with two staff in Early Preschool , and 17 children with two staff in preschool 2, and there were 11 children with one staff in Pre-K Room.


During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staffing ratios. Facility hours are 6:30 am - 6:00 pm., Monday through Friday. Parents sign their children in and out electronically and manually if needed to.
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 (cleaning compounds, and medications) were observed to be stored out of the reach of children. Poisons/Hazardous Items are not kept on the premises. The facility provides PM snack to school age children. Menu is posted. Floors, equipment, and furniture were clean and were observed to be in good repair and free of sharp edges. Drinking water is available to children indoors by water containers that children bring from home and the facility fill them up with filtered water if need to.
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NAME OF LICENSING PROGRAM MANAGER: Thuy Ho
NAME OF LICENSING PROGRAM ANALYST: Mahnaz Malek
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: TUTOR TIME CHILD CARE/LEARNING CENTER
FACILITY NUMBER: 304370256
VISIT DATE: 06/18/2025
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The facility has been conducted an emergency drill within the past six months. The last fire drill was conducted on 5/23/2025.
The facility has a working carbon monoxide detector and fire extinguisher. Facility met all posting requirement.

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 on the preschool playground is appeared to be enough to absorb falls under the climbing structures and slides. (wood chip). Drinking water in the outdoor activity space is provided by water containers children bring from home and the facility fills them up with filtered water. The outdoor equipment and toys were in good repair and free of sharp edges. Shade is provided by canopies. There are no bodies of water present at the facility. Exit gated opening to outdoor playground were inspected. They were all locked with padlock and latch on the top of the gates. These gates are not used for entering and exiting the playground during school's operation.

Staff files were reviewed for staff present during the facility inspection on this date, seven staff file was reviewed. Health screening and immunization 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 childcare center if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles for staff were reviewed and were in 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 shall possess current EMSA approved Pediatric CPR/First Aid certifications. They were not in compliance.

Children's records were reviewed, and there was a separate, complete and current record for each child. A random sample of 5 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 compliance.
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NAME OF LICENSING PROGRAM MANAGER: Thuy Ho
NAME OF LICENSING PROGRAM ANALYST: Mahnaz Malek
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025
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: TUTOR TIME CHILD CARE/LEARNING CENTER
FACILITY NUMBER: 304370256
VISIT DATE: 06/18/2025
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Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care
Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test. For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP). LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP on 08/04/22. An inspection from the department was conducted on 9/8/2022 for lead exceedance. The director showed documents today that the facility was re-tested on 9/14/2022 and the results showed no lead exceedance.

LPA provided Guardian Information and website info:
https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian

LPA reviewed storage of “medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301(voice) or (800) 514-0383 (TTY) and link to publication. Commonly Asked Questions about Child Care Centers and the ADA are available at:https://www.ada.gov/resources/child-carecenters

The facility representative, Mary Joy Hilsabeck 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, except as specified in Health and Safety Code section 1596.871, 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 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.

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 Continued on page 4

NAME OF LICENSING PROGRAM MANAGER: Thuy Ho
NAME OF LICENSING PROGRAM ANALYST: Mahnaz Malek
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025
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: TUTOR TIME CHILD CARE/LEARNING CENTER
FACILITY NUMBER: 304370256
VISIT DATE: 06/18/2025
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important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communications.

The facility representative, Maryjoy Hilsabeck 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.

To improve the quality and value of the new inspection process, a survey may be sent to the


email address provided. Please complete the survey and share your inspection experience. If
you have any questions regarding the process or CARE tools, please send email inquiries to
inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its
tools and methods, please visit the Program website at
www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

A notice of site visit was given to facility representative, Maryjoy Hilsabeck and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

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


Exit interview conducted and report was reviewed with the facility representative, Maryjoy Hilsabeck

End of report.

NAME OF LICENSING PROGRAM MANAGER: Thuy Ho
NAME OF LICENSING PROGRAM ANALYST: Mahnaz Malek
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/18/2025 03:33 PM - It Cannot Be Edited


Created By: Mahnaz Malek On 06/18/2025 at 01:58 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: TUTOR TIME CHILD CARE/LEARNING CENTER
FACILITY NUMBER: 304370256

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(f)
Personnel Requirements
(f) At least one staff member who is trained in pediatric cardiopulmonary resuscitation and pediatric first aid pursuant to Health and Safety Code Section 1596.866 shall be present when children are at the child care center or offsite for center activities.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on reviewing 7 staffs' flies, the licensee did not comply with the section cited above in 7 out of 7 files missing current CPR and 1st aid Certificates which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2025
Plan of Correction
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The director agreed to sing up the staff to renew the required certificate. The director will send copies of the certificates of staff to LPA's email address by the due date of 7/9/2025.
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.
Thuy Ho
NAME OF LICENSING PROGRAM MANAGER:
Mahnaz Malek
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2025


LIC809 (FAS) - (06/04)
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