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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304370698
Report Date: 03/10/2023
Date Signed: 03/10/2023 05:39:55 PM

Document Has Been Signed on 03/10/2023 05:39 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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:COUNTRY VILLAGE PRESCHOOL FOOTHILL RANCHFACILITY NUMBER:
304370698
ADMINISTRATOR:FERGUSON, JENNIFERFACILITY TYPE:
830
ADDRESS:27005 BURBANK ROADTELEPHONE:
(949) 380-4300
CITY:FOOTHILL RANCHSTATE: CAZIP CODE:
92610
CAPACITY: 12TOTAL ENROLLED CHILDREN: 12CENSUS: 4DATE:
03/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:TIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Tran and LPA Nunez conducted an onsite inspection for the purpose of an Annual Inspection. LPA 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 4 infants and 1 staff member. 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 7a.m.- 6p.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.

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. Bottles, dishes, and containers were labeled with infants’ names were visible on all children's bottles and other refrigerated items. The facility takes measures to keep the facility free of flies, other insects, and rodents. Food is properly stored. Bottles and food containers brought from home are properly labeled with name and date. Trash receptacles containing solid waste have tight fitting lids. Poisons/Hazardous Items are not kept on the premises. Food is prepared on site. Food prep areas were clean and sanitary. 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 water bottle. The children's bathrooms are clean and sanitary. Children sleep in cribs, there are individual crib for each infant in care. Crib was observed with loose fitted sheets. 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. (Continue next page)
SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Nguyen K Tran
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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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: COUNTRY VILLAGE PRESCHOOL FOOTHILL RANCH
FACILITY NUMBER: 304370698
VISIT DATE: 03/10/2023
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(Page 2 of Report)

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 and free of hazards. 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 water 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 safe, sanitary and in good repair.

Staff files were reviewed for staff present during the facility inspection on this date. 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 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.

Children's records were reviewed, and there was a separate, complete and current record for each child. LPA observed 2 infants from 0-12 months. Facility did not complete LIC 9227 Individual Infant Sleeping Plan and Sleep Log for the 4 infants in care. Violation was observed and being cited on Complaint Report LIC 9099D. 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.

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

(Continue next page)
SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Nguyen K Tran
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
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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: COUNTRY VILLAGE PRESCHOOL FOOTHILL RANCH
FACILITY NUMBER: 304370698
VISIT DATE: 03/10/2023
NARRATIVE
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(Page 3 of Report)

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.

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 101419.2(b)(2) Infant Needs and Services Plan, 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.
(Continue next page)
SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Nguyen K Tran
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
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 03/10/2023 05:39 PM - It Cannot Be Edited


Created By: Nguyen K Tran On 03/10/2023 at 01:52 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: 304370698

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 Director admitted that the facilty had not completed the lead testing requirment for the center as of 03/10/2023, facility did not comply with the section cited above, which poses a potential health and personal rights risk to persons in care.
POC Due Date: 04/10/2023
Plan of Correction
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Director states she will submit a details plan of correction to complete the Lead Testing for the center before due date.
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.
SUPERVISOR'S NAME:Rina Lopez
LICENSING EVALUATOR NAME:Nguyen K Tran
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2023


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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: COUNTRY VILLAGE PRESCHOOL FOOTHILL RANCH
FACILITY NUMBER: 304370698
VISIT DATE: 03/10/2023
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(Page 4 of Report)

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)
SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Nguyen K Tran
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
LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 03/10/2023 05:39 PM - It Cannot Be Edited


Created By: Nguyen K Tran On 03/10/2023 at 04:49 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: 304370698

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101419.2(b)(2)
Infant Needs and Services Plan
(b) The needs and services plan shall be in writing and shall include the following: (2) Infants up to 12 months of age shall have a completed Individual Infant Sleeping Plan [LIC 9227 (3/20)], which is incorporated by reference.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the Director admitted that staff did not comply with the section cited above in 4 out of 4 infant's files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/17/2023
Plan of Correction
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Director will submit LIC 9227 for the infants in care to LPA by due date
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.
SUPERVISOR'S NAME:Rina Lopez
LICENSING EVALUATOR NAME:Nguyen K Tran
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2023


LIC809 (FAS) - (06/04)
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