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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371614
Report Date: 12/06/2023
Date Signed: 12/06/2023 02:05:03 PM

Document Has Been Signed on 12/06/2023 02:05 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:PACIFIC ACADEMYFACILITY NUMBER:
304371614
ADMINISTRATOR:XFACILITY TYPE:
850
ADDRESS:2987 MESA VERDE DRIVE ETELEPHONE:
(833) 796-5688
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 60TOTAL ENROLLED CHILDREN: 60CENSUS: DATE:
12/06/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:11 PM
MET WITH:Tiffanny PoonTIME COMPLETED:
03:00 PM
NARRATIVE
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On 12/06/2023 the licensing program analyst conducted a case management visit and met with the director Tiffanny Poon.

Census: Room4C- 8 Children and 1 Staff / Room 4D- 5 Children and 1 Staff

The facility representative was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, before initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

LPA interviewed staff regarding vermin in the facility, it was determined that the facility had a vermin problem. LPA interviewed staff regarding health & safety procedures for food preparation while the facility has been dealing with vermin in their kitchen. LPA interviewed staff 1-5 and it was determined that the facility staff were not washing the cutting boards that were left out on the counter. The cutting boards are used to cut snack. The facility staff handbook is not specific on procedures of food preparation, the LPA requested proof of food preparation training certificates and none were obtain during the visit. During the 12/06/2023 visit the director demonstrated to the LPA training agenda from 4 of 4 staff present in the facility.

During the case management visit an incident that occurred on 08/30/2023 was disclosed.

On 09/20/2023 LPA interviewed 4 staff members at the facility. LPA interviewed S1 on 10/28/2023. S2-S4 mentioned an incident that occurred on 08/30/2023 where S1 put C1 inside an empty classroom while having an emotional outburst. S1 asked S2 and S3 to lock the door from the outside, while S1 stayed in the room with C1. Both S2 and S3 declined to lock the door during the incident. S1 remained in the empty classroom with the door shut with C1 during the incident for approximately 5 min mentioned by S2.
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2023
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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: PACIFIC ACADEMY
FACILITY NUMBER: 304371614
VISIT DATE: 12/06/2023
NARRATIVE
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12/06/2023 S2 and S3 mentioned that the facility door for the classroom S1 attempted to lock themselves in with C1 did not have a lock. Therefore the door could not be locked and physically keep a child restrained in an area. It was determined that C1 was not treated with dignity in his/her personal relationship with staff during this incident and the facility will be cited for personal rights.

On 09/20/2023, LPA conducted interviews with 3 (C1-C3) children. 1 out of the three children interviewed on that date was assessed using a combination of color-related questions and a truth/lie series. 1 of 3 children made no disclosures of personal rights being violated.

On 09/20/2023, LPA reached out to nine parents. Out of these nine parents contacted on that day, zero engaged in conversations with LPA.

On 09/20/2023, LPA reviewed C1’s record for incident reports and communication logs. LPA obtained a copy of the incident report communication with the C1’s caregiver about the incident that occurred on 08/30/2023.
S3 mentioned that the incident was not reported to CCLD.

Based on LPA’s interviews conducted with 5 staff members. The facility violated C1’s rights and failed to report it to Community Care Licensing. A consultation was provided on reporting requirements.

Based on LPA’s record review and staff interviews, the licensee did not comply with the section cited above by not reporting the unusual incidents that threatened the physical and emotional health or safety of C1’s while in care which poses an immediate health, and safety or personal rights risk to children in care.

The facility did not meet the California Code of Regulations, Title 22 Division 12, and regulations not met were observed, discussed, and cited at the time of the visit.

The following violations of the California Code of Regulations, Title 22; Division 12, were observed and cited today: 101227(14) Food Services, 102423, (a)(3) Personal Rights and 101212(d)(C) Reporting Requirements

An exit interview was conducted with Director, Tiffanny Poon. Notice of Site Visit was posted during the visit. The director was informed that the notice of the site visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100. The director was provided a copy of their appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. First-level appeals should be sent to the regional manager at the address listed above
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/06/2023 02:05 PM - It Cannot Be Edited


Created By: Araceli Bootorabi On 12/06/2023 at 11:48 AM
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: PACIFIC ACADEMY
FACILITY NUMBER: 304371614

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/06/2023
Section Cited
CCR
101223(a)(3)

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(a) The licensee shall ensure that each child is accorded the following personal rights(3)To be free from ... unusual punishment... including but not limited to: interference with functions of daily living including... physical functioning.Based on LPA's staff interviews and record review
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The principle of the school mentioned that she will be conducting a training with staff pertaining to children's personal rights. A training was conducted on 09/15/2023 with staff a copy of the agenda was provided.
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the licensee did not comply with the section cited above by means of S1 attempting to restrain C1 in a empty classroom and requesting for it to be locked by other staff which poses a potwntial health, safety and personal rights risk to children in care.
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Type B
12/06/2023
Section Cited
CCR101227(14)

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101227(14)Food Service: All persons engaged in food preparation and service shall observe personal hygiene and food-service sanitation practices that protect food from contamination. Based on LPA's staff interview, the licensee did not comply with the section cited above by means of not
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The director states that all staff will had a training pertaining to hygiene procedures when preparing meals for the children. The director mentions that all-new staff will receive the same training. The director mentions even in the classroom the new practice is using gloves to support children while they are having their meal and cleaning utensils in the kitchen when preparing snacks. The principle demonstrated a newsletter emailed to staff on 10/01/2023 regarding food safety preparation.
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following food preparation hygiene practices to ensure food, and food preparation utensil are not contaminated with vermin exposures
which poses an immediate health, safety or personal rights 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:Patricia Magana
LICENSING EVALUATOR NAME:Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/06/2023 02:05 PM - It Cannot Be Edited


Created By: Araceli Bootorabi On 12/06/2023 at 11:55 AM
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: PACIFIC ACADEMY
FACILITY NUMBER: 304371614

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/06/2023
Section Cited
HSC
101212(d)(C)

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 Reporting Requirements Upon the occurrence, during the operation of the childcare center of any of the events specified ...a report shall be made to the Departmen.. In addition, a written report containing the information ...shall be submitted..including unusual incident that threatens
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The principle and director reviewed the reporting requirements and are aware of the requirements.
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 the physical or emotional health or safety of any child. Based on LPA’s record review and staff interviews, the licensee did not comply with the section cited above by not reporting the unusual incidents that threatened the physical and emotional health or safety of C1’s while in care which poses a potential health, and safety or personal rights 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:Patricia Magana
LICENSING EVALUATOR NAME:Araceli Bootorabi
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023


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