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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371157
Report Date: 02/05/2026
Date Signed: 02/05/2026 03:11:44 PM

Document Has Been Signed on 02/05/2026 03:11 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:ANDREWS HEAD STARTFACILITY NUMBER:
304371157
ADMINISTRATOR/
DIRECTOR:		PORRAS, IRENEFACILITY TYPE:
830
ADDRESS:1231 E. CHAPMAN AVENUETELEPHONE:
(714) 241-8920
CITY:FULLERTONSTATE: CAZIP CODE:
92831
CAPACITY: 16TOTAL ENROLLED CHILDREN: 16CENSUS: 11DATE:
02/05/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:38 AM
MET WITH:Director Irene PorrasTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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On 02/05/25 at 11:20am, Licensing Program Analyst (LPA), Anna Chan conducted an unannounced onsite inspection for the purpose of an Annual Random Visit. LPA met with Director Irene Porras and toured the facility inside and outside and the floor and yard plan were verified. Census was taken in individual classrooms. The overall census observed was 11 infant children and 5 staff. Children were having lunch when LPA arrived. Director stated currently, there are 16 children enrolled in the infant license.

During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staffing ratios. Facility hours are 7:30a.m.- 5:30p.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.

All staff is fingerprint associated through a master file under Matt Kline Headstart (300603968)

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. Food is provided through Great American Lunch and delivers food at the facility. Menus are posted where they can be seen by parents in the classrooms. Water is provided by a filtered water and Brita water dispenser and sports bottles with children’s name on it. LPA observed the changing tables in the 2 infant rooms were not within arm's reach of a sink. The director stated they use the changing table to change infant diapers and children are not potty trained.

Children nap on cribs and cots. Beddings were stored individually. Sheets and blankets are washed by the facility daily. The facility has a working carbon monoxide detector and fire extinguisher.

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NAME OF LICENSING PROGRAM MANAGER: Martha Malane
NAME OF LICENSING PROGRAM ANALYST: Anna Francesca Chan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/05/2026
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 COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: ANDREWS HEAD START
FACILITY NUMBER: 304371157
VISIT DATE: 02/05/2026
NARRATIVE
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The facility conducted an emergency drill on 01/20/26. Facility met all posting requirement. The California Child Passenger Safety Law was posted by the entrance of the facility.

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 playground has a turf grass around the climbing structure which appears to be enough to absorb falls Drinking water in the outdoor activity space is provided by purified water and sports bottled with the children’s name on it. The outdoor equipment and toys were in good repair and free of sharp edges. There are no bodies of water at the premises.

4 Staff files were reviewed for the facility inspection on this date. Health screening and immunization as required were reviewed. Beginning September 1, 2016, Health and Safety (H&S) 1596.7995 (a)(1) 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.

Proof of immunization against pertussis, measles for the facility were reviewed and within compliance.

Beginning March 31, 2018, H&S Code 1596.8662 requires all directors and employees to complete mandated reporter 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 08/2027.

6 Children's records were reviewed, and there was a separate, complete, and current record for each child. Based of record review, 3 of 6 children’s file showed 3 children are over the age of 24 months. The facility is licensed for ages 0-2years old. Sign in/out procedure through ChildPlus app was reviewed for compliance. 15-minute sleep check was reviewed through Learning Genie app.

Currently, there are no medications in the facility. 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 Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. 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

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NAME OF LICENSING PROGRAM MANAGER: Martha Malane
NAME OF LICENSING PROGRAM ANALYST: Anna Francesca Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2026
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 COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: ANDREWS HEAD START
FACILITY NUMBER: 304371157
VISIT DATE: 02/05/2026
NARRATIVE
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LPA discussed safe sleep regulations 101430 Infant Care Activities and 101429
Responsibility for Providing Care and Supervision for Infants with the 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. A sample of every 15-minute check on children under 24 months old during nap time for logging was given to the applicant.

Safe Sleep FAQ was provided. The FAQ states that sleep sacks are an alternative form of swaddling therefore require an exception shall be considered on a case-by-case basis.

English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf
AAP: https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx
NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative
Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials
· Always place infants on their backs for sleeping
· Use only a tight-fitting sheet on the crib or play yard mattress
· There shall be no objects hanging above or attached to the side of the crib.
· Keep all items, including blankets, out of the crib or play yard
· Pacifiers may be used as long as they do not have items attached to them
· Infants should not be swaddled or have any items covering them while sleeping
· The temperature of the room should be comfortable enough for an adult to wear a t-shirt and not be too hot or too cold

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NAME OF LICENSING PROGRAM MANAGER: Martha Malane
NAME OF LICENSING PROGRAM ANALYST: Anna Francesca Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2026
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 COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: ANDREWS HEAD START
FACILITY NUMBER: 304371157
VISIT DATE: 02/05/2026
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CCC COMPLETED TESTING AND NO LEAD EXCEEDANCES: 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 on 3/18/23 in accordance to the Written Directives outlined in PIN 21-21.1-CCP.

In the areas that were evaluated, the following violation was observed, in accordance with California Code of Regulations, Title 22, Division 12, Section 101439(h)(4) Infant Care Center Fixtures, Furniture, Equipment and Supplies. Section 101161(a) Limitations on Capacity. 2 Type B violation is being cited on the attached LIC 809D. Civil Penalty assessed

An Inspection and exit interview were completed with Director Irene Porras. The report and deficiencies were reviewed discussed. “Notice of Site Visit” was provided and must be posted for 30 consecutive days. Appeal rights were provided.

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NAME OF LICENSING PROGRAM MANAGER: Martha Malane
NAME OF LICENSING PROGRAM ANALYST: Anna Francesca Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/05/2026 03:11 PM - It Cannot Be Edited


Created By: Anna Francesca Chan On 02/05/2026 at 02:25 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: ANDREWS HEAD START
FACILITY NUMBER: 304371157

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101439(h)(4)
Infant Care Center Fixtures, Furniture, Equipment and Supplies
(h) Infant changing tables shall: (4) While in use, be placed within arm's reach of a sink.

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 the changing table is not placed within arm's reach of a sink in the 2 infant rooms which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/05/2026
Plan of Correction
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Director stated Headstart Admin is working with the Regional Office on the changing table issue and a plan of action document will be provided to LPA by due date 3/5/26
Type B
Section Cited
CCR
101161(a)
101161 Limitations on Capacity
(a) A licensee shall not operate a child care center beyond the conditions and limitations specified on the license, including the capacity limitation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in 3 of 6 children's file showed 3 children are over the age of 24 months in the infant license which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/05/2026
Plan of Correction
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Director stated Headstart Admin is working with the Regional Office on the age issue and a plan of action document will be provided to LPA by due date 3/5/26
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Martha Malane
NAME OF LICENSING PROGRAM MANAGER:
Anna Francesca Chan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2026


LIC809 (FAS) - (06/04)
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