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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364846174
Report Date: 09/15/2022
Date Signed: 09/15/2022 02:15:59 PM

Document Has Been Signed on 09/15/2022 02:15 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 ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:FAIRYTALE CASTLE PRESCHOOLFACILITY NUMBER:
364846174
ADMINISTRATOR:ROSA LOPEZFACILITY TYPE:
850
ADDRESS:710 EAST FOOTHILL BLVDTELEPHONE:
(626) 567-5678
CITY:UPLANDSTATE: CAZIP CODE:
91786
CAPACITY: 116TOTAL ENROLLED CHILDREN: 116CENSUS: 48DATE:
09/15/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Laura Perez TIME COMPLETED:
02:35 PM
NARRATIVE
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On 09/15/2022 at 10:00 a.m., Licensing Program Analysts (LPAs) Blanca Ruiz and Destinee Hogue arrived at the facility to conduct an inspection for a separate purpose. During this inspection, LPAs toured the facility, took census and verified staff's criminal record clearances and association to facility.

While touring the facility and verifying facility associations, LPAs observed three staff members present and working at the facility without an Eligible Criminal Record Clearance.

In accordance with Title 22 Regulation, 101170(h) Violation of Section 101170(e) will result in an immediate assessment of civil penalties of one hundred dollars ($100) per violation per day for a maximum of five (5) days by the Department.

See LIC809D for cited deficiency. A Civil Penalty has been assessed during this inspection. Payment is due when billed and the check(s) or money orders shall be made payable to the “California Department of Social Services”. YOU WILL RECEIVE AN INVOICE IN THE MAIL. DO NOT SEND MONEY UNTIL YOU RECEIVE YOUR INVOICE. DO NOT SEND CASH.

An exit interview was conducted and upon receipt of this report, the Director shall post any licensing report documenting a Type A deficiency (LIC809 & LIC809D). The report and the Notice of Site Visit shall be posted for 30 days. A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled children for the next 12 months. The Acknowledgement of Receipt (LIC9224) form must be maintained in each child’s file immediately upon receipt from the parent. Licensee was provided with a copy of the Acknowledgement of Receipt of Licensing Reports (LIC9224).
SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Blanca Ruiz-Silva
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2022
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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Document Has Been Signed on 09/15/2022 02:15 PM - It Cannot Be Edited


Created By: Blanca Ruiz-Silva On 09/15/2022 at 11:18 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: FAIRYTALE CASTLE PRESCHOOL
FACILITY NUMBER: 364846174

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/16/2022
Section Cited
CCR
101170(e)(1)

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101170(e)(1) Criminal Record Clearance. (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption...
This requirement is not met as evidenced by:
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During this inspection, Director uploaded LIC9182-Criminal Background Clearance Transfer Request, LIC508-Criminal Record Statement, and Copy of DL/ID card to Guardian website for Staff #1, Staff #2 and Staff #3. LPAs provided associations _disasociations862@dss.ca.gov email.
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Based on records review and observation, facility did not comply with the section cited above in which LPAs observed three staff members present and working at the facility without an Eligible Criminal Record Clearance. Staff N.1-N.3 This poses an immediate health, safety, and personal rights risk to children in care.
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During this inspection, the facility called CCL 951-782-4200 to verify pending fingerprints and processing. A civil penalty is being assessed. Staff N.1 and Staff N.2 left during the facility during this inspection.

Facility called Guarding and cleared Staff N.3 Licensee understand that Staff N.1 and Staff
N.2 can not return to work until clearance has been confirmed.

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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:Aaron Ross
LICENSING EVALUATOR NAME:Blanca Ruiz-Silva
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022


LIC809 (FAS) - (06/04)
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