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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371423
Report Date: 04/19/2022
Date Signed: 04/19/2022 04:13:34 PM

Document Has Been Signed on 04/19/2022 04:13 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:KIDDIE ACADEMY OF YORBA LINDAFACILITY NUMBER:
304371423
ADMINISTRATOR:CORTEZ,GLORIETTEFACILITY TYPE:
850
ADDRESS:18633 YORBA LINDA BLVD.TELEPHONE:
(714) 660-6111
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY: 120TOTAL ENROLLED CHILDREN: 142CENSUS: 50DATE:
04/19/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Gloriette Cortez, DirectorTIME COMPLETED:
04:30 PM
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Licensing Program Analyst, (LPA) P Rivas conducted an unannounced case management visit to investigate incident reports dated 03/30/22 and 04/01/22(2) and 04/12/22 provided by Director, Cortez. The Covid-19 Emergency Response questionnaires were asked. Census; 50 children and 6 staff members.
A review of facility Personnel Report Summary on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

In the incident of 03/30/22 it involved Children 1 (C1 and C2 and through investigation C3).
The first incident of 04/01/22 it involved C4, C5. The second incident of 04/01/22 involved C6,C7; The incident reported on 04/12/22 involved C6, C8, C9.

In reference to the first incident of 04/01/22 it was reported by C1's authorized representative that C1's had been taken to urgent care and found that C1 had nurse's elbow. However, Director reports no injuries were observed by staff during the day on 03/30/22 it was photo day and children did not play outside until the PM. Some teachers did call out. During today's visit, LPA interviewed 3 staff and 3 children. Staff interviews revealed that they had not observed child being hurt,. They did however see C2 near C1 and C2 has had previous incidents of pulling on other children. LPA interviewed C1, C2, C3. LPA was unable to qualify C2 and C3. However, LPA's interview with C1 indicated they had been hurt by C3 not C2 but no other details provided. Staff 1(S1) stated they were in ratio with 1 staff and 11 children. Interview with staff indicated they had interceded between C1 and C2 but was also interceding for incident involving C3 at the same time and did not observe anyone pulling or pushing C1. Based on interviews and records reviewed no violation was observed. LPA was advised facility is striving for 8 to 1 ratio.LPA did advise Director to also consider children's needs in reference to ratios.
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SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Pat Rivas
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2022
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 2
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: KIDDIE ACADEMY OF YORBA LINDA
FACILITY NUMBER: 304371423
VISIT DATE: 04/19/2022
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The second incident investigated is the first of 04/01/22 which involved C4 and C5, S2 and S3. LPA interviewed 9 children and staff from 9am to 3pm. It was reported that C4 during transition from outside to inside the classroom, child tripped over a friend in front of them and hit the floor, causing an injury to child’s upper gum on the right hand, injuring two teeth; however, the teeth were not loose. Interview with staff indicated S2 was in front of the line and S3 was behind the line with 17 children. C5 did not want to return to classroom and dropped to the floor causing C4 to trip and fall. Based on interviews, review of records, LPA did not observe any violation of Title 22 Regulations.

The third incident being investigated is second incident of 04/01/22 involved C6,C7. LPA interviewed 9 children and staff from 9 am to 3PM.. C6 was unavailable for interview. LPA interviewed 1 staff regarding this incident. LPA was provided an unusual incident report for C7 which was investigated In November 2021 and no deficiencies were noted. Due to insufficient information available further investigation is required.

The fourth incident being investigated was reported on 04/12/22 involved C6, C8, C9, C10. LPA received copy of incident report, all children involved in this incident were not present during today's visit. LPA interviewed 9 other children and one staff from 9am to 3pm. Due to insufficient information available further investigation is required.

Exit interview conducted and report was reviewed with Director Cortez. Appeal Rights were explained, Director was provided a copy of her Appeal Rights and signature on this form acknowledges receipt of these rights. Director was informed 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. Failure to post will result in civil penalties of $100.00. The Notice of Site Visit must be posted on or adjacent to the door.


SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Pat Rivas
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022
LIC809 (FAS) - (06/04)
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