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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371734
Report Date: 02/23/2026
Date Signed: 02/23/2026 12:54:17 PM

Document Has Been Signed on 02/23/2026 12:54 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 COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:LA CRISTIANITA PRESCHOOLFACILITY NUMBER:
304371734
ADMINISTRATOR/
DIRECTOR:		CASABIANCA, CAITLYNFACILITY TYPE:
860
ADDRESS:35522 CAMINO CAPISTRANOTELEPHONE:
(949) 496-1405
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92672
CAPACITY: 90TOTAL ENROLLED CHILDREN: 90CENSUS: 62DATE:
02/23/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Facility Representative, Shelby ReynoldsTIME VISIT/
INSPECTION COMPLETED:
01:10 PM
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On 2/23/2026 Licensing Program Analyst (LPA), K. Trinh conducted an inspection for the purpose of an Annual Random Inspection. LPA and Facility Representative, Shelby Reynolds, toured the facility inside and outside according to the facility sketch (LIC 999). The overall census observed was 5 infants with 2 infant staff, 7 toddlers with 2 toddler staff, and 50 preschool children with 6 preschool staff. During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staffing ratios. Facility hours are 7AM-6PM, Monday through Friday. 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. Based on record review, 11 of the staff present during today's inspection have their criminal record clearance, but are not associated to the facility; see LIC 809D for deficiency.

During the inspection of the indoor activity space, items which could pose a danger to children (detergents, cleaning compounds, and medications) were observed to be stored out of the reach of children. Poisons/Hazardous Items are not kept on the premises. Snacks are provided; lunch is brought from home. Food prep areas were clean and sanitary. Food is properly stored. Menus were posted where they could be reviewed by parents. Floors, equipment, and furniture were clean and were observed to be in good repair and free of sharp edges. There is drinking water available to children indoors by refillable bottles with the child’s name on it. The children's bathrooms are clean and sanitary. Children nap on cots, and bedding was not stored individually; see LIC 809D for deficiency. Bedding in the toddler and preschool classrooms is taken home weekly to be washed by parents or facility washes blankets at end of week. The infant bedding is washed on a daily basis or as needed at the facility.

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NAME OF LICENSING PROGRAM MANAGER: Tina Nguyen
NAME OF LICENSING PROGRAM ANALYST: Kathy Trinh
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: LA CRISTIANITA PRESCHOOL
FACILITY NUMBER: 304371734
VISIT DATE: 02/23/2026
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(Page 2) The facility conducted an emergency drill on 2/10/2026. The facility has a working carbon monoxide detector and fire extinguisher. Facility met all posting requirement. The California Child Passenger Safety Law was posted by the entrance of the facility.

The facility does not practice potty training in the infant center. Infant napping area had individual cribs with tight fitted sheets. Infant changing tables have a padded surface no less that one inch thick and, are covered by washable vinyl/plastic, and is within arm’s reach of a hand-washing sink. Infant changing tables have raised sides at least three inches high. A baby walker is not allowed on the premises of a childcare center. The facility did not have documentation of infant's 15 minute sleep log available for review. The start and end time of infant's naps are recorded on an application called Bright Wheel. Bright wheel does not have documentation that staff are visually checking on the infants every 15 minutes and are documenting it; see LIC 809D for deficiency.

The outdoor activity space was inspected for compliance. The playground was enclosed by a fence at least four feet in height. The surface of the outdoor activity space was well maintained and free of hazards. The cushioning material, sand and rubber mats, commercially produced for the purpose around the climbing equipment and other similar equipment appeared to be enough to absorb falls. Drinking water in the outdoor activity space is provided by refillable bottles with the child’s name on it and a water fountain. The outdoor equipment and toys were in good repair and free of sharp edges. There are no bodies of water present at the facility. The facility was safe, sanitary, and in good repair.

Five (5) staff files were reviewed during the facility inspection on this date. There was a separate, complete and current record for each staff. Health screening and immunizations as required were reviewed. Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a childcare center if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles for staff were reviewed and were within compliance. Beginning March 31, 2018, H&S Code 1596.8662 requires all directors and employees to complete mandated reporting training, and to renew the training every two years. At least one staff member present possesses current EMSA approved Pediatric CPR/First Aid certifications, which expires 8/2026.

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NAME OF LICENSING PROGRAM MANAGER: Tina Nguyen
NAME OF LICENSING PROGRAM ANALYST: Kathy Trinh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2026
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 COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: LA CRISTIANITA PRESCHOOL
FACILITY NUMBER: 304371734
VISIT DATE: 02/23/2026
NARRATIVE
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(Page 3)

Six (6) children's records were reviewed. There was not a separate, complete and current record for each child. Child 1 (C1) did not have the LIC 9227 or Needs and Services Plan in file for review; see LIC 809D for deficiency. Sign in/out procedure was reviewed for compliance. The person who signs the child in and out uses their full legal signature and records the time of the day. Facility uses an electronic application called Bright Wheel with a unique code to sign in and out child.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test as specified in Health and Safety Code section 1597.16.

For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP.).

LPA verified that the lead testing was completed in accordance to the Written Directives (Interim Licensing Standards) outlined in PIN 21-21.1-CCP.

LPA referred facility representative to the Department website for lead: Lead Toxicity Prevention and Water Testing Information (https://www.cdss.ca.gov/inforesources/child-care-licensing/water-testing-information)

Facility completed testing and no lead exceedances.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22- 02-CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514- 0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

The facility representative was informed that Licensing Quarterly Updates are available at www.ccld.ca.gov facility representative may request to be added to an email list to receive a Quarterly Update by contacting the Child Care Advocate at [email protected] or at www.ccld.ca.gov

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NAME OF LICENSING PROGRAM MANAGER: Tina Nguyen
NAME OF LICENSING PROGRAM ANALYST: Kathy Trinh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2026
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 COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: LA CRISTIANITA PRESCHOOL
FACILITY NUMBER: 304371734
VISIT DATE: 02/23/2026
NARRATIVE
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(Page 4)

LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian

Information on the additional nutrition training, immunization requirements for children, and Health Schools Act (http://www.cdpr.ca.gov/docs/pestmgt/schoolipm.htm) were provided. The facility representative was informed, and website given, about the California Child Care Disaster Plan has been posted to the UCSF California Childcare Health Program website: cchp.ucsf.edu/content/disaster-preparedness Also provided was information about the E-Learning Modules available at https://ccld.childcarevideos.org A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the facility representative. Facility Director does have lead training Certificate.

LPA discussed the safe sleep regulations with facility representative and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed facility representative of the importance of checking for and removing any recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Facility representative was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

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, prior to 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.

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NAME OF LICENSING PROGRAM MANAGER: Tina Nguyen
NAME OF LICENSING PROGRAM ANALYST: Kathy Trinh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2026
LIC809 (FAS) - (06/04)
Page: 5 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: LA CRISTIANITA PRESCHOOL
FACILITY NUMBER: 304371734
VISIT DATE: 02/23/2026
NARRATIVE
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(Page 5) Based on LPAs observations and record reviews the following violations were observed are being cited in accordance with California Code of Regulations, Title 22, Division 12, Chapter 3, Section 101239.1(c)(2), 101429(a)(2)(C), 101419.2(a), 101419.2(b)(2), and 101170(f), are being cited on the attached LIC 809D.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to [email protected]. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters, and other important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/communitycare-licensing/subscribe and select the Child Care option to receive email communication.

If you have any questions regarding the process or CARE tools, please send email inquiries to [email protected]. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

A notice of site visit was given to facility representative and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Exit interview conducted and report was reviewed with the facility representative, Shelby Reynolds.

Appeal Rights were explained. The Licensee was provided a copy of 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. First level appeals should be sent to the regional manager to the address listed above.

End of report.

NAME OF LICENSING PROGRAM MANAGER: Tina Nguyen
NAME OF LICENSING PROGRAM ANALYST: Kathy Trinh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2026
LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 02/23/2026 12:54 PM - It Cannot Be Edited


Created By: Kathy Trinh On 02/23/2026 at 12:11 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: LA CRISTIANITA PRESCHOOL
FACILITY NUMBER: 304371734

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101239.1(c)(2)
Napping Equipment
(c) Each cot or mat shall be equipped with a sheet to cover the cot or mat and, depending on the weather, a sheet and/or blanket to cover the child. (2) Bedding shall be individually stored so that each child's bedding is identifiable and no child's used bedding comes into contact with other bedding.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above in that the children's bedding was observed to be stored outside of the classrooms, with the children's bedding coming into contact with one another which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/09/2026
Plan of Correction
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Assistant Director stated that the facility will set up the children's bedding before bed time. When the bedding is not being used, the facility will store it in the children's bags. Assistant Director will send LPA photos of the children's bedding being stored in the children's bags by due date.
Type B
Section Cited
CCR
101429(a)(2)(C)
Responsibility for Providing Care and Supervision for Infants
(C) Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that the facility did not have documentation of the infant's 15 minute sleep log available for review which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/09/2026
Plan of Correction
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3
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Assistant Director stated that the infant classroom will go back to using the Infant Sleep Observation form which documents the infant names, nap duration, 15 minute observations with staff initials, and comments with the infant's sleeping position. Assistant Director will send LPA a copy of the completed Infant Sleep Observation form by due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Tina Nguyen
NAME OF LICENSING PROGRAM MANAGER:
Kathy Trinh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/23/2026 12:54 PM - It Cannot Be Edited


Created By: Kathy Trinh On 02/23/2026 at 12:11 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: LA CRISTIANITA PRESCHOOL
FACILITY NUMBER: 304371734

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101419.2(a)
Infant Needs and Services Plan
(a) Prior to the infant's first day at the center, the infant care center director or assistant director shall complete a needs and services plan for the infant.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in that Child 1 (C1) did not have a needs and services plan in file for review which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/09/2026
Plan of Correction
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Assistant Director stated that they have provided a copy for C1's authorized representatives to complete. Once the facility receives C1's completed needs and services plan, Assistant Director will send LPA a copy by due date.
Type B
Section Cited
CCR
101419.2(b)(2)
Infant Needs and Services Plan
(b) The needs and services plan shall be in writing and shall include the following: (2) Infants up to 12 months of age shall have a completed Individual Infant Sleeping Plan [LIC 9227 (3/20)], which is incorporated by reference.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in that Child 1 (C1) did not have the LIC 9227 in file for review which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/09/2026
Plan of Correction
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3
4
Assistant Director stated that they have provided a copy for C1's authorized representatives to complete. Once the facility receives C1's completed LIC 9227 form, Assistant Director will send LPA a copy by due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Tina Nguyen
NAME OF LICENSING PROGRAM MANAGER:
Kathy Trinh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2026


LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 02/23/2026 12:54 PM - It Cannot Be Edited


Created By: Kathy Trinh On 02/23/2026 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: LA CRISTIANITA PRESCHOOL
FACILITY NUMBER: 304371734

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101170(f)
(f) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from TrustLine to a state licensed facility by providing the following documents to the Department:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in that 11 staff present at the facility have their criminal record clearance, but are not associated to the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/09/2026
Plan of Correction
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2
3
4
Assistant Director stated that they provided a copy of the LIC 9182 to all staff that have not been associated to the facility. Assistant Director will email the LIC 9182 to the office email to have the staff associated. Assistant Director will send LPA proof of association by due date.
Section Cited
Deficient Practice Statement
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2
3
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POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Tina Nguyen
NAME OF LICENSING PROGRAM MANAGER:
Kathy Trinh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2026


LIC809 (FAS) - (06/04)
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