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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 330910505
Report Date: 08/26/2021
Date Signed: 08/26/2021 01:32:49 PM

Document Has Been Signed on 08/26/2021 01:32 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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:CHILDTIME CHILDREN'S CENTERFACILITY NUMBER:
330910505
ADMINISTRATOR:SURIATI C. CAFAROFACILITY TYPE:
850
ADDRESS:14700 PERRIS BLVD.TELEPHONE:
(951) 242-0707
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 73TOTAL ENROLLED CHILDREN: 0CENSUS: 14DATE:
08/26/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Suriati Cafaro-Director TIME COMPLETED:
01:35 PM
NARRATIVE
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During the course of the investigation, LPA verified that an incident report was not filed with CCLD by phone within 24 hours of the incident occurring or paper form within 7 days as the required time frame by the Director or Assistant Director.

Assistant Director stated, she did fill out the form and emailed it to CCLD. When the LPA asked her to provide proof of the email that was sent, the director stated she could not find it. Therefore (see LIC 809D for deficiency)

Exit interview conducted with the Director and Notice of Site visit given. LPA observed posting.

Appeal rights issued and discussed.
SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: Lakesha Edwards
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2021
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
Document Has Been Signed on 08/26/2021 01:32 PM - It Cannot Be Edited


Created By: Lakesha Edwards On 08/26/2021 at 01:05 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
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: CHILDTIME CHILDREN'S CENTER
FACILITY NUMBER: 330910505

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/02/2021
Section Cited
CCR
101212(d)(1)(E)

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101212 (d)(1)(E) Reporting Requirements
(d) Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1)... a report shall be made to the Department by telephone or fax within the Department's next working day and within 7 days.(E) Epidemic outbreaks.

This requirement was not met as evidenced by:
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Director has agreed to have a refresher training with the assistant director and other staff on Title 22 Regulations 101212 (d)(1)(E) Reporting Requirements and submit proof of training to CCLD by the POC due date. Assistant Director provided an LIC 624 UIR to the LPA during the visit.
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Based on interviews conducted, A child tested positive for Covid and the facility did not call CCLD withn 24 hours of knowledge of positive case or submit an LIC 624 UIR within 7 days. Assistant Director Stepanie Acosta stated she submitted via email but could not provide proof of the email that was sent to the LPA during the visit.

This poses a potential risk to the health and safety of 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:Pauline Beschorner
LICENSING EVALUATOR NAME:Lakesha Edwards
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2021


LIC809 (FAS) - (06/04)
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