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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304370432
Report Date: 03/10/2023
Date Signed: 03/16/2023 05:02:31 PM

Document Has Been Signed on 03/16/2023 05:02 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 FOOTHILL RANCHFACILITY NUMBER:
304370432
ADMINISTRATOR:FERGUSON, JENNIFERFACILITY TYPE:
850
ADDRESS:27005 BURBANK ROADTELEPHONE:
(949) 380-4300
CITY:FOOTHILL RANCHSTATE: CAZIP CODE:
92610
CAPACITY: 158TOTAL ENROLLED CHILDREN: 158CENSUS: 57DATE:
03/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Licensee, Jennifer FergusonTIME COMPLETED:
12:00 PM
NARRATIVE
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On March 10, 2023 Licensing Program Analyst (LPA) Tran and (LPA) Nunez conducted an onsite inspection for the purpose of an Annual Inspection and returned to the facility on March 16, 2023 for a continuation of the Annual Inspection. LPAs Tran and Nunez and the facility representative 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 57 children. During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staff to child ratios. Facility hours are 8a.m.- 5p.m. 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. Director was reminded that all adults 18 and over, 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.

Staff files were reviewed for staff present during the facility inspection on this date. Seven out of Seven staff files were reviewed. Staff#1 did not have an LIC 503 in personnel file. Staff#2 did not have a TB clearance in personnel file. Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a child care center if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles for staff members 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 06/2023.

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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Aiddee Nunez
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2023
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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Document Has Been Signed on 03/16/2023 05:02 PM - It Cannot Be Edited


Created By: Aiddee Nunez On 03/16/2023 at 02:20 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 FOOTHILL RANCH
FACILITY NUMBER: 304370432

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101238(g)
Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 count out of 1 item, LPA observed a cleaning bottle, that stated Keep out of reach of children, located in a low shelf that is accessible to the children in the playground, which posed a potential health, safety risk to persons in care.
POC Due Date: 03/27/2023
Plan of Correction
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Director immediately removed the cleaning bottle. Director states she would be submitting a statement of understanding of the regulation and a plan to ensure the the regulation is followed, to LPA by due date.
Type B
Section Cited
HSC
1597.16(a)(1)
Lead Testing
(1) A licensed child day care center, as defined in Section 1596.76, that is located in a building that was constructed before January 1, 2010, shall have its drinking water tested for lead contamination levels on or after January 1, 2020, but no later than January 1, 2023, and every five years after the date of the initial test.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above, Director admitted that facility has not completed Lead Testing as of 03/16/2023, which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/16/2023
Plan of Correction
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Director states she will submit a detailed plan to complete the Lead testing and will submit all required document for LPA by the due date.
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:Thuy Ho
LICENSING EVALUATOR NAME:Aiddee Nunez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2023


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 03/16/2023 05:02 PM - It Cannot Be Edited


Created By: Aiddee Nunez On 03/16/2023 at 02:20 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 FOOTHILL RANCH
FACILITY NUMBER: 304370432

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2023

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
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Based on record review, the licensee did not comply with the section cited above in 1 out of 1 staff, staff #1 did not have form LIC 503 Health Screening, which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/23/2023
Plan of Correction
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Director states that she will be submitting the LIC 503 for staff #1 to LPA by the due date.
Type B
Section Cited
CCR
101217(a)(12)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) Tuberculosis test documents as specified in Section 101216(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 1 staff, 1 staff did not have record of a TB test, which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/23/2023
Plan of Correction
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Director states that she will be submitting the TB test staff #2 to LPA by the due date.
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:Thuy Ho
LICENSING EVALUATOR NAME:Aiddee Nunez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2023


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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 FOOTHILL RANCH
FACILITY NUMBER: 304370432
VISIT DATE: 03/10/2023
NARRATIVE
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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. Floors, equipment, and furniture were clean and observed to be in good repair and free of sharp edges. There is drinking water available to children indoors by the children’s water bottles. The children's bathrooms are clean and sanitary. Children nap on cots, bedding is stored individually and is taken home weekly to be washed by parents. The facility has conducted an emergency drill within the past six months and keeps documentation of drills. The facility has a at least one working smoke detector, one working carbon monoxide detector and at least one functioning fire extinguisher. Facility meets all posting requirements. The facility has not completed the lead testing as of 03/16/2023 according to the Director.

The outdoor activity space was inspected for compliance. The playground is enclosed by a fence at least four feet in height and is in good repair. The surface of the outdoor activity space is maintained. On 03/10/2023, LPAs observed a cleaning bottle, that stated Keep out of reach of children, located in a low shelf that is accessible to the children in the playground. The cushioning material around outdoor play equipment and other similar equipment appeared to be enough to absorbs falls. Drinking water in the outdoor activity space is provided by drinking bottles. The outdoor equipment and toys are in good repair and free of sharp edges. There are no bodies of water present at the facility. The inspected outdoor facility grounds are sanitary and in good repair.


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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Aiddee Nunez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023
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 FOOTHILL RANCH
FACILITY NUMBER: 304370432
VISIT DATE: 03/10/2023
NARRATIVE
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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. The toddler's files did not have Sleep log prior to 03/10/2023. Staffs admitted that the facility did not complete Sleep log for the toddlers in care prior to 03/10/2023. Sign in/out procedure was reviewed for compliance during the inspection. The person who signs the child in and out uses their full legal signature and records the time of the day.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. 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 Director was informed that Licensing Quarterly Updates are available at www.cdss.ca.gov 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.cdss.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 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.

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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Aiddee Nunez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023
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 FOOTHILL RANCH
FACILITY NUMBER: 304370432
VISIT DATE: 03/10/2023
NARRATIVE
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LPA discussed the safe sleep regulations with Director and 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 Director 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.

Based on LPAs' observations, record reviews and interviews, the following violations were observed in accordance with Health and Safety Code, Section 1597.16(a)(1) Lead Testing and in accordance to California Code of Regulation Section 101238(g) Buildings and Grounds,101216(g)(1) Personnel Requirements, 101217(a)(12) Personnel Records, are being cited on the attached LIC 809D; and 101419(a)(2)(C) Responsibility for Providing Care and Supervision for Infants, is being cited on the complaint investigation report LIC 9099D.

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


To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

End of report

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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Aiddee Nunez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023
LIC809 (FAS) - (06/04)
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