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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371447
Report Date: 07/09/2021
Date Signed: 07/09/2021 01:03:33 PM

Document Has Been Signed on 07/09/2021 01:03 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:CATALYST KIDS-SPRINGBROOKFACILITY NUMBER:
304371447
ADMINISTRATOR:VILLAGOMEZ, MARGARITAFACILITY TYPE:
840
ADDRESS:655 SPRINGBROOK NORTHTELEPHONE:
(949) 559-8388
CITY:IRVINESTATE: CAZIP CODE:
92614
CAPACITY: 70TOTAL ENROLLED CHILDREN: 0CENSUS: 10DATE:
07/09/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Margarita VillaGomez, DirectorTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mila Quinto conducted a case management inspection in response to a self-reported incident on June 28, 2021. LPA and staff, Justine Hernandez toured the facility inside and outside and the floor and yard plan were verified. Census was taken and the overall census observed were 2 staff and 10 school age children. Director, Margarita Villagomez arrived at 10am. During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staffing ratios. 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.

On 06/28/21 the facility self-reported that on 6/23/21 at 4:40pm, the 2 staff were transitioning the children in care from the restroom back to the classroom. During this time, a parent arrived at 4:41pm to pick up child and notice the child was walking back from the restroom without supervision. A staff looked over towards the restroom and saw the child walking out from the restroom.

LPA interviewed 3 staff members regarding the incident. Based on the information gathered through interviews and records, it was confirmed that child was left in the restroom without supervision for a period of 1 minute. Staff reports that it was an oversight that occurred during transitioning of the children. This poses an immediate health and safety risk to the children in care.

The facility self-reported the incident on June 28, 2021 regarding the incident that took place on June 23, 2021. During the course of the investigation, LPA interviewed director regarding the reporting requirements. The director is aware of the reporting requirements within 24 hours on unusual incident. However, during this timeline, director discussed with the parents and the program director prior to contacting licensing.
SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Mila Quinto
LICENSING EVALUATOR SIGNATURE: DATE: 07/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/09/2021
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: CATALYST KIDS-SPRINGBROOK
FACILITY NUMBER: 304371447
VISIT DATE: 07/09/2021
NARRATIVE
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California Code of Regulations, Title 22, Division 12 Section 101229(a)(1), Responsibility for Providing Care and Supervision is being cited on the attached LIC 809D. This report cites a Type A violation and shall be provided to parents/guardians of children currently in enrolled and to parents/guardians of children newly enrolled at the facility during the next 12 months. Parents/guardians must sign Form LIC9224 to be kept in each child's file; 101212(a) Reporting Requirements is also being cited on the attached LIC 809D.

An exit interview was completed with director. The report was reviewed and discussed. 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. If the facility receives a Type A violations, the licensee shall post and provide copies of the report to parents/guardians of the children in care at the facility by the next business day, and shall provide to the parents/guardians of children newly enrolled at the facility during the next 12 months. In addition, the licensee shall immediately post upon receipt the Proof of Correction for 30 consecutive days and provide a copy to current and enrolling parents. The licensee is to keep Acknowledgement Receipt (LIC 9224) signed by parents in each child’s file. Failure to post Type A reports for 30 days will result in a Civil Penalty of $100.00

Exit interview was conducted. Notice of Site Visit was posted during the visit. Coordinator was informed that the notice of site visit must be posted for 30 consecutive days.
SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Mila Quinto
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/09/2021 01:03 PM - It Cannot Be Edited


Created By: Mila Quinto On 07/09/2021 at 12:12 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: CATALYST KIDS-SPRINGBROOK
FACILITY NUMBER: 304371447

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/09/2021
Section Cited
CCR
101229(a)(1)

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101229 Responsibility for Providing Care and Supervision
(a) The licensee shall provide care and supervision... (1) No child(ren) shall be left without the supervision of a teacher at any time...
This requirement is not met as evidenced by:
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The director provided training to staff and will be conducting more thorough head count and the facility has created new procedures for transitioning children to insure all children are accounted for throughout the day.
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Based on records and interviews, the facility failed to provide supervion from 4:40pm-4:41pm during the transition from the restroom back to the classroom.
This poses an immediate safety risk to children in care.
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In accordance with the California Health and Safety Code Section 1596.99(c), you are hereby notified that an immediate $500 civil penalty per violation.

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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:Mila Quinto
LICENSING EVALUATOR SIGNATURE:
DATE: 07/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2021


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/09/2021 01:03 PM - It Cannot Be Edited


Created By: Mila Quinto On 07/09/2021 at 12:26 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: CATALYST KIDS-SPRINGBROOK
FACILITY NUMBER: 304371447

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/16/2021
Section Cited
CCR
101212(d)

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101212 Reporting Requirements (d)Upon the occurrence, during the operation of the child care center of any of the events ...a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours.
This requirement is not met as evidenced by:
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The director will immediately contact licensing office within 24 hour period and or the following business day for any unusual incident reports.
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Based on interview and records reviewed, Director did not report the unusual incident within 24 hours.
This poses a potential safety risk to children in care.
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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:Mila Quinto
LICENSING EVALUATOR SIGNATURE:
DATE: 07/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2021


LIC809 (FAS) - (06/04)
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