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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304370309
Report Date: 11/09/2023
Date Signed: 11/09/2023 01:28:30 PM

Document Has Been Signed on 11/09/2023 01:28 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 COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:BRIGHT STAR LEARNING CENTERFACILITY NUMBER:
304370309
ADMINISTRATOR:COGLIANESE, JUDITHFACILITY TYPE:
850
ADDRESS:6621 GLEN DRIVETELEPHONE:
(714) 895-4063
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY: 139TOTAL ENROLLED CHILDREN: 139CENSUS: 24DATE:
11/09/2023
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Assistant Director Jennifer BelchTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA), Romy Castanon conducted an onsite inspection for the purpose of an Annual. LPA and Assistant Director Jennifer Belch toured two individual preschool classrooms and the preschool playground. There were 24 preschool children and 5 staff present at the time of LPA’s visit. The floor and yard plan (LIC 999) were verified. Facility hours are Monday through Friday 7:00am – 5:00pm.

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, LPA did not observe any items which could pose a danger to children (poisons, detergents, cleaning compounds, medications or hazardous items). The children bring their own water bottles and are refilled using the facility sinks that have been tested and are considered safe for consumption. The facility also provides disposable water cups. The children's restrooms/diaper changing areas are clean and sanitary. LPA advised the Assistant Director to rearrange the diaper changing station in the Yellow Ducks room closer to the sink. Bedding for napping is brought from home, stored individually and taken home weekly to be laundered.

The facility provides morning and afternoon snacks. The children bring their own lunch from home. The areas and surfaces where snack food is prepared and stored were clean and sanitary. Menus were posted where they could be reviewed by parents.

The facility has conducted an emergency drill within the past six months, last conducted on 09/07/2023. The facility has a working carbon monoxide detector, fire alarm and fire extinguisher that meets statutory and State Fire Marshal standards. Facility met all posting requirements. The California Child Passenger Safety Law was posted by the entrance of the facility office.

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SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Romelia M Castanon
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2023
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 5

Created By: Romelia M Castanon On 11/09/2023 at 12:17 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: BRIGHT STAR LEARNING CENTER

FACILITY NUMBER: 304370309

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
1
2
3
4
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center 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
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
1
2
3
4
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:Patricia Magana
LICENSING EVALUATOR NAME:Romelia M Castanon
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2023


LIC809 (FAS) - (06/04)
Page: of

Created By: Romelia M Castanon On 11/09/2023 at 12:19 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: BRIGHT STAR LEARNING CENTER

FACILITY NUMBER: 304370309

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(g)(1)
Personnel Requirements
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
1
2
3
4
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Patricia Magana
LICENSING EVALUATOR NAME:Romelia M Castanon
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2023


LIC809 (FAS) - (06/04)
Page: of
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: BRIGHT STAR LEARNING CENTER
FACILITY NUMBER: 304370309
VISIT DATE: 11/09/2023
NARRATIVE
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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 sand and woodchip material commercially produced for the purpose around the climbing equipment, structures, slides and other similar equipment appeared to be enough to absorbs falls. The children use their water bottles in the outdoor space and are refilled with the facility sinks as needed. The outdoor equipment and toys were free of sharp edges. There are no bodies of water present at the facility. The facility grounds were safe, sanitary and in good repair.

Four staff files were reviewed. Health screening and immunizations 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. 3 out of 4 proof of immunization against pertussis, measles for staff were 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. 3 out of 4 staff members had Mandated Reporter Training that are current and do not expire until 11/2024. At least one staff member present possesses current EMSA approved Pediatric CPR/First Aid certifications, which is also current and will not expire until 10/2025.

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 Assistant Director was informed that Licensing Quarterly Updates are available at www.ccld.ca.gov Assistant Director 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

Continue to page 3
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Romelia M Castanon
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023
LIC809 (FAS) - (06/04)
Page: 1 of 1
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: BRIGHT STAR LEARNING CENTER
FACILITY NUMBER: 304370309
VISIT DATE: 11/09/2023
NARRATIVE
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Director was reminded that all adults 18 and over, 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.

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 childcare 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 on 02/10/2023. The results determined there was no lead exceedance in accordance to the Written Directives outlined in PIN 21-21.1-CCP.

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 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-care-centers/.

In the areas that were evaluated, the following deficiencies were observed of the California Code of Regulations, Title 22, Division 12 and Health & Safety Code 1596.8662. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Assistant Director Jennifer Belch.

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.

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. (End of Report)

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Romelia M Castanon
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023
LIC809 (FAS) - (06/04)
Page: 1 of 1
Document Has Been Signed on 11/09/2023 01:28 PM - It Cannot Be Edited


Created By: Romelia M Castanon On 11/09/2023 at 12:44 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: BRIGHT STAR LEARNING CENTER

FACILITY NUMBER: 304370309

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's record review of staff files, the licensee did not comply with the section cited above in 1 out of 4 staff members did not have a mandated report training certificate of proof training was completed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2023
Plan of Correction
1
2
3
4
Assistant Director stated Staff #1 will complete the training and the copy of certificate will be emailed to LPA by POC date. Assistant Director will create individual licensing folders for each staff member and a checklist of documents to ensure all forms are submitted upon hire.
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center 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
1
2
3
4
Based on LPA's record review of staff files, the licensee did not comply with the section cited above in 1 out of 4 staff have been working since 09/19/2023 and did not have proof of immunizations which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2023
Plan of Correction
1
2
3
4
Assistant Director stated Staff #1 will submit their proof of immunzation and a copy will be sent to LPA by POC date. Assistant Director will create individual licensing folders for each staff member and a checklist of documents to ensure all forms are submitted upon hire.
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:Patricia Magana
LICENSING EVALUATOR NAME:Romelia M Castanon
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2023


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 11/09/2023 01:28 PM - It Cannot Be Edited


Created By: Romelia M Castanon On 11/09/2023 at 12:44 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: BRIGHT STAR LEARNING CENTER

FACILITY NUMBER: 304370309

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(g)(1)
Personnel Requirements
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's record review, the licensee did not comply with the section cited above in 1 out of 4 staff members did not have LIC503 or screening of good physical health and TB test verified by a clinician which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2023
Plan of Correction
1
2
3
4
Assistant Director stated Staff #1 will obtain a health screening and a copy will be submitted to LPA by POC date. Assistant Director will create individual licensing folders for each staff member and a checklist of documents to ensure all forms are submitted upon hire.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Patricia Magana
LICENSING EVALUATOR NAME:Romelia M Castanon
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: BRIGHT STAR LEARNING CENTER
FACILITY NUMBER: 304370309
VISIT DATE: 11/09/2023
NARRATIVE
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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 sand and woodchip material commercially produced for the purpose around the climbing equipment, structures, slides and other similar equipment appeared to be enough to absorbs falls. The children use their water bottles in the outdoor space and are refilled with the facility sinks as needed. The outdoor equipment and toys were free of sharp edges. There are no bodies of water present at the facility. The facility grounds were safe, sanitary and in good repair.

Four staff files were reviewed. Health screening and immunizations 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. 3 out of 4 proof of immunization against pertussis, measles for staff were 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. 3 out of 4 staff members had Mandated Reporter Training that are current and do not expire until 11/2024. At least one staff member present possesses current EMSA approved Pediatric CPR/First Aid certifications, which is also current and will not expire until 10/2025.

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 Assistant Director was informed that Licensing Quarterly Updates are available at www.ccld.ca.gov Assistant Director 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

Continue to page 3

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Romelia M Castanon
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023
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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: BRIGHT STAR LEARNING CENTER
FACILITY NUMBER: 304370309
VISIT DATE: 11/09/2023
NARRATIVE
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Page 3

Director was reminded that all adults 18 and over, 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.

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 childcare 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 on 02/10/2023. The results determined there was no lead exceedance in accordance to the Written Directives outlined in PIN 21-21.1-CCP.

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 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-care-centers/.

In the areas that were evaluated, the following deficiencies were observed of the California Code of Regulations, Title 22, Division 12 101216(g)(1) as well as Health & Safety Code 1596.8662(b)(1) and 1596.7995(a)(1).

Exit interview conducted and report was reviewed with the Assistant Director Jennifer Belch. A notice of site visit was given and must remain posted for 30 days.
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.

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. (End of Report)

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Romelia M Castanon
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5