l STATE OF CALIFORNIA~ HEALTH AND HUMAN SERVICES AGENCY CAUFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNJTY CARE LlCENSING DMSION FACILITY EVALUATION REPORT CCLD Regional Office, 3737 MAIN ST., SUITE 700 RIVERSIDE, CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL ADMINISTRATOR: ALLISON BERKEMEIR ADDRESS: 9488 19TH STREET CITY: RANCHO CUCAMONGA CAPACITY: 85 TYPE OF VISIT: Case Management MET WITH: Allison Berkemeir 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 FACILITY NUMBER: FACILITY TYPE: TELEPHONE: STATE:CA ZIP CODE: CENSUS: 21 DATE: UNANNOUNCED TIME BEGAN: TIME COMPLETED: 364809858 850 (909) 483-8250 91701 03/26/2014 10:40 AM 01:35PM NARRATIVE LPAs Kim Leung and Teresa Aguiar conducted a case management visit this date at the facility. Upon arrival, LPAs observed Vector Control Technicians from West Valley Mosquito and Vector Control District present at the facility. Per Vector Control Technician, an inspection was conducted on 3/20/14 and dead cockroaches were found at the facility. During this visit, Vector Control Technician confirmed that facility had been treated by pest control on 3/25/14 and currently, no live or dead cockroaches or droppings were seen this date. Vector Control required the facility to have pest control services on a monthly basis. LPAs toured the kitchen with Vector Control Technicians and observed that the garbage disposal has been replaced, kitchen wall has been cleaned to remove grease. LPAs toured the facility and observed no cockroaches or droppings this date. During visit, LPAs observed Ms. Venita Parrish supervising children in Room 107 together with another teacher. Ms. Parrish is NOT associated to the facility. LPAs reviewed staff file and observed no proof of submission of written request for association on file. Per staff, Ms. Parrish has been working at the facility since 3/3/14. Licensee Mr. Hal Hazegh stated that he was responsible for hiring staff and submitting association request to CCL. He stated that the request was submitted to CCL via Internet and he stated that the cover page was the proof of submission. However, later on Mr. Hazegh submitted to LPAs a document stating that that was the proof of submission that the fax was submitted to CCL successfully. By reviewing the document obtained from Mr. Hazegh, LPAs could not determined that it was not adequate to support that complete written request was submitted to CCL successfully to associate Ms. Parrish prior to having Ms. Parrish supervising children at the facility. During visit, LPAs advised director Allison Berkemeir to contact CCL each time after any request for association has been submitted as a follow up to ensure that each staff's criminal record clearance has been successfully associated to the facility. See UC809D for deficiency cited. SUPERVISOR'S NAME: AnHa Hise TELEPHONE: (951) 782-4200 LICENSING EVALUATOR NAME: Kim Leung TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: .e:&:~,.......-4 . . ~)1.........-.;"--"l) ~ DATE: 03/26/2014 .... I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/26/2014 This report must be available at Child Care and Group Home facilities for public review for 3 years. UC809 {FAS) • (06104) Page: 1 of 3 STATE OF CALIFORNIA- HEALTH AND HUMAN SERViCES AGENCY CAliFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office 3737 MAIN ST., SUITE 700 RIVERSIDE, CA 92501 09/2212011 RANCHO HERITAGE SCHOOL 364809858 9488 19TH STREET RANCHO CUCAMONGA, CA 81701 Letter of Deficiency Citations Cleared Dear Licensee, The following deficiencies, initially cited during a visit on 09/01/2011, have been cleared: Section Cited: 101229(a)(1) Plan of Correction: Date Due: 09/0112011 Corrections: An immediate civil penally of$150 per day will be assessed. Facility was cited for lack of supervision on 1217/2010. Progressive civil penalty will be assessed. The employee has completed Child Care Center Orientation Component Ill on 8/18/2011. Licensee will provide training to all staff on supervision and Received training proof. LICENSING EVALUATOR NAME: Ki Ying Kim Leung Clearance Date: 09/0112011 TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2011 This report must be available at Child Care and Group Home facilities for public review for 3 years. Cleared POC Letter (FAS)- (04/05) Page: 1 of 2 STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office 3737 MAIN ST., SUITE 700 RIVERSIDE, CA 92501 09/22/2011 RANCHO HERITAGE SCHOOL 364809858 COMMENTS Please be advised of the following requirement per California Health & Safety Code: Per Section 1596.859S(b) the licensee shall post the "Letter of Deficiency Citations Cleared" verifying the licensee's compliance or noncompliance with the department's order (LIC809D or LIC 9099D) to correct a type A deficiency that is subject to posting for a period of 30 days. The "Letter of Deficiency Citations Cleared" shall be posted immediately upon receipt, immediately adjacent to, the interior side of the main door into the facility and shall be posted for a period of 30 consecutive days. Failure to comply shall result in an immediate civil penalty of one hundred dollars ($1 00). LICENSING EVALUATOR NAME: Ki Ying Kim Leung TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2011 This report must be available at Child Care and Group Home facilities for public review for 3 years. Cleared poe Letter (FAS)- (06104} Page: 2 of 2 STATE OF CALIFORNIAw HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FACILITY EVALUATION REPORT CCLO Regional Office, 3737 MAIN ST., SUITE 700 RIVERSIDE, CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL ADMINISTRATOR: MASTANEH HAZEGH ADDRESS: 9488 19TH STREET CITY: RANCHO CUCAMONGA CAPACITY: 85 TYPE OF VISIT: Case Management MET WITH: Hal Hazegh 1 2 3 4 5 6 FACILITY NUMBER: FACILITY TYPE: TELEPHONE: STATE:CA ZIP CODE: DATE: CENSUS: 24 UNANNOUNCED TIME BEGAN: TIME COMPLETED: 364809858 850 (909) 483-8250 91701 09/01/2011 08:25AM 10:55 AM NARRATIVE LPA Kim Leung visited the facility conducting complaint investigation. During visit, LPA reviewed children's records and found an incident report in file documented that a child was left alone on the playground in the afternoon on 7/19/2011 after outdoor activities. It was disclosed that after outdoor activities, teacher escorted the children back to the activity room from the playground and was not aware of missing one child from the group until another staff member stepped in the room to take census. It was disclosed that the child was found alone on the playground after approximately 3 to 5 minutes. 7 8 See LIC809D for deficiency cited per California Code of Title 22, Division 12. 9 10 11 An exit interview was conducted, appeal rights discussed, Notice of Site Visit was posted and must stay posted for 30 days. A copy of this report was provided. Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. A Fact Sheet of AB633 and LIC9224 were provided to facility during visit. 12 13 14 15 16 A copy of this report must be made available for 3 years for public review upon request. 17 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME: Marianne Donley TELEPHONE: (951) 782-4200 LICENSING EVALUATOR NAME: Ki Ying Kim Leung TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2011 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2011 This report must be available at Child Care and Group Home facilities for public review for 3 years. UC809 (FAS)- {06/04} Page: 1 of3 STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FACILITY EVALUATION REPORT(Cont) CCLD Regional Office, 3737 MAIN ST., SUITE 700 RIVERSIDE, CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL DEFICIENCY INFORMATION FOR THIS PAGE: FACILITY NUMBER: 364809858 VISIT DATE: 09/01/2011 Deficiency Type PLAN OF CORRECTIONS(POCs) DEFICIENCIES POC Due Date I Section Number Type A 09/01/2011 Section Cited 101229(a)(1) 1 2 3 4 specified in sections 101216.2(e)(1) and 5 101230(c)(1 ). A child was left alone on the 6 playground on 7/19/2011 after outdoor activities. It 6 7 was disclosed that after outdoor 7 1 2 3 4 5 8 9 10 11 12 13 14 Care and Supervision. No child{ren) shall be left without the supervision, including visual observation, of a teacher at any time except as activities, teacher and children back to the activity room from the playground and was not aware of missing one child from the group until another staff member stepped in the room to take census. It wa's disclosed that the child was found alone on the playground after approximately 3 to 5 minutes. 8 submit proof of training with staff signatures as 9 proof of correction. 10 11 12 13 14 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 1 2 3 4 5 6 7 5 6 7 An immediate civil penalty of $150 per day will be assessed. Facility was cited for lack of supervision on 12/7/2010. Progressive civil penalty will be assessed. The employee has completed Child Care Center Orientation Component Ill on 8/18/2011. Licensee will provide training to all staff on supervision and 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: Malia nne Donley TELEPHONE: (951) 782-4200 LICENSING EVALUATOR NAME: Ki Ying Kim Leung TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2011 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE:" DATE: 09/01/2011 This Notice must be posted for 30 days LIC809 (FAS)- (06104} Page: 2 of3 STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSING DIVISION FACILITY EVALUATION REPORT(Cont) CCLD Regional Office, 3737 MAIN ST., SUITE 700 RIVERSIDE, CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL DEFICIENCY INFORMATION FOR THIS PAGE: Deficiency Type POC Due Date I Section Number Type B 09/02/2011 Section Cited 101212(d} FACILITY NUMBER: 364809858 VISIT DATE: 09/01/2011 DEFICIENCIES 1 2 3 4 5 6 7 Reporting Requirements. A report shall be made to the Department within 24 hours of the occurrence of any unusual incident as specified. A child was left alone on the playground on 7119/2011 after outdoor activities. Licensee failed to report the incident to Licensing as required. PLAN OF CORRECTIONS(POCs) 1 Licensee will submit written unusual incident report 2 to CCL by 9/2/2011. 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 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: Marianne Donley TELEPHONE: (951) 782-4200 LICENSING EVALUATOR NAME: Ki Ying Kim Leung TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2011 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2011 LIC809 (FAS)- (06104) Page: 3 of3 STATE OF CALIFORNIA~ HEALTH AND HUMAN SERVICES AGENCY COMPLAINT INVESTIGATION REPORT CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DMSION CCLD Regional Office, 3737 MAIN ST., SUITE 700 RIVERSIDE, CA 92501 This is an official report of an unannounced visit/investigation of a complaint received in our office on 08/26/2011 and conducted by Evaluator Ki Ying Kim Leung PUBLIC COMPLAINT CONTROL NUMBER: 09-CC-2011 0826153115 FACILITY NAME: RANCHO HERITAGE SCHOOL ADMINISTRATOR:MASTANEH HAZEGH ADDRESS: 948819TH STREET CITY: RANCHO CUCAMONGA CAPACITY: 85 MET WITH: Mastaneh Hazegh FACILITY NUMBER: FACILITY TYPE: TELEPHONE: STATE: ZIP CODE: CENSUS:24 DATE: UNANNOUNCED TIME VISIT BEGAN: TIME COMPLETED: 364809858 850 (909) 483-8250 91701 09/0112011 08:25AM 10:55AM ALLEGATION(S): 1 Personal Rights- Child received injury 2 3 Physical Plant- Wobbly toilet seat 4 5 6 7 8 9 INVESTIGATION FINDINGS: 1 LPA Kim Leung visited the facility conducting complaint investigation. Upon arrival, LPA met with front office 2 staff Ms. Michelle Verdugo. LPA informed Ms. Verdugo the purpose of the visit was to investigate a complaint 3 During visit, licensee Hal Hazegh and director Mastaneh Hazegh arrived at the facility meeting with the LPA 4 LPA toured the facility inspecting the toilet seats in each activity room. LPA observed that the two toilet seats 5 in the two's bathroom appeared to be wobbly that the seats moved approximately two inches to each sides of 6 the toilet. LPA conducted interviews and reviewed records. There is an incident report documented that on 7 7/18/2011 that a child had the thigh pinched between the toilet seat and the rim of the toilet. Licensee Hal 8 Hazegh stated that he was aware of the incident and he had tightened the loose plastic screw of one of the 9 toilets after the incident. However, the toilet seats still appeared wobbly upon LPA's arrival this date. LPA 10 inspected the toilet seats again together with Mr. Hazegh and Mr. Hazegh tightened the screws during visit and 11 further agrees to make necessary repair to prevent pinches or injuries. This complaint is therefore 12 substantiated. 13 Substantiated SUPERVISOR'S NAME: Marianne Donley Estimated Days of Completion: TELEPHONE: (951) 782-4200 LICENSING EVALUATOR NAME: Ki Ying Kim Leung TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: 6~7 DATE: 09/01/2011 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: ~~ DATE: 09/01/2011 This report must be available at Child Care and Group Home facilities for public review for 3 years. UC9099 (FAS) • (06/04) Page: 1 of 3 Control Number 09-CC-2011 0826153115 STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY CAUFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSING DIVISION COMPLAINT INVESTIGATION REPORT (Cont) CCLD Regional Office, 3737 MAIN ST., SUITE 700 RIVERSIDE, CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL FACILITY NUMBER: 364809858 VISIT DATE: 09/01/2011 NARRATIVE 1 2 3 4 5 6 7 8 9 10 See LIC9099D for deficiencies cited per California Code of Title 22, Division 12. An exit interview was conducted, appeal rights discussed, Notice of Site Visit was posted and must stay posted for 30 days. A copy of this report was provided. Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children In care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. A Fact Sheet of AB633 and LIC9224 were provided to facility during visit. A copy of this report must be made available for 3 years for public review upon request. 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 SUPERVISOR'S NAME: Marianne Donley TELEPHONE: (951) 782-4200 LICENSING EVALUATOR NAME: Ki Ying Kim Leung TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2011 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2011 UC9099 (FAS)- (OG/04) Page: 2 of3 Control Number 09-CC-20110826153115 STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION COMPLAINT INVESTIGATION REPORT (Cont) CCLD Regional Office, 3737 MAIN ST., SUITE 700 RIVERSIDE, CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL DEFICIENCY INFORMATION FOR THIS PAGE: FACILITY NUMBER: 364809858 VISIT DATE: 09/01/2011 Deficiency Type POC Due Date I DEFICIENCIES PLAN OF CORRECTIONS(POCs) Section Number Type A 09/02/2011 Section Cited 101223(a)(2) 1 2 3 4 5 Personal Rights. Each child shall be accorded safe, healthful and comfortable accommodations, furnishings and equipment. The two toilet seats in the two's bathroom appeared to be wobbly that the seats moved approximately two inches to each 6 sides of the toilet. On 7/1812011 that a child had 7 the 1 2 3 4 5 Ucensee agrees to make necessary repair to prevent pinches or injuries. A written statement and repair receipt wlU be submitted to CCL by 9/2/2011 after repair has been made. 6 7 8 thigh pinched between the toilet seat and the rim of 8 Type A 09102/2011 Section Cited 101239(n) 9 the toilet. 10 11 12 13 14 9 10 11 12 13 14 1 Fixtures, Furniture, Equipment and Supplies. 2 Furniture and equipment shall be in good condition, 3 free of sharp, loose, or pointed parts. The two 4 toilet seats in the two's bathroom appeared to be 5 wobbly that the seats moved approximately two 6 inches to each sides of the toilet. On 7/18/2011 7 that a child had the thigh Ucensee agrees to make necessary repair to 2 prevent pinches or injuries. A writtert statement 3 and repair receipt will be submitted to CCL by 4 9/2/2011 after repair has been made. 5 6 7 8 pinched between the toilet seat and the rim of the 9 toilet. 10 11 12 13 14 8 9 10 11 12 13 14 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: Marianne Donley TELEPHONE: (951) 782-4200 LICENSING EVALUATOR NAME: Ki Ying Kim Leung TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2011 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2011 This Notice must be posted for 30 days UC9099 (FAS) ~ (06/04) Page: 3 of 3 STATE OF CAUFORNIA -HEALTH AND HUMAN SERVtCES AGH CALIFORNIA DEPARTMENT OF SOCIAL SI:ORV!CES f'liOTICE OF CIVIL PENALTIES DUE 0 0 Initial Invoice INVOICE NO. 0901899 Final Notice FILE COPY DISTRICT OR COUNTY OFFICE NUMBER _o9_..1H_..3_..09:....__ _ ASCAL YEAR FAC!UTY NAMI:O Rancho Heritage School 2007/2008 FACIU1Y TYPE FACIUTY ADDRESS 850 9488 Nineteenth Street CITY CA 08/12/2011 PENALTY PCACOOE 84030 ZIP CODE STATE Rancho Cucamonga DATE LIC 422 SENT 91701 IFACIUTY NUMBER 364809858 UCENSEE(S) OR UNLICENSED FACIUTY OPERAlOR Rancho Heritage School ADDRESS DATE 08/12/11 9235 Baseline Road CITY ZJPCODE STATE Rancho Cucamonga CA 91730 The California Health and Safety Code, Sections 1548, 1568.0822, 1569.49, 1596.99, and 1597.62 provides for the imposition of civil penalties against any facility which fails to take corrective action within prescribed time periods. The California Health and Safety Code, Sections 1547, 1568.0821, 1569.485, 1596.89, 1596.891 and 1597.61 provides for the imposition of civil penalties against any unlicensed facility which fails to take corrective action within prescribed time periods. The California Health and Safety Code, Sections 1522, 1568.09, 1569.17, 1596.871, and 1596.8712 provides for the imposition of immediate civil penalties against any facility which fails to comply with fingerprinting or other criminal background requirements. Your facility has been found in violation of Community Care Licensing statutes and regulations. Failure to correct the deficiency(ies} cited on the Licensing Report (LIC 809 or LIC 9099} dated,_0_9_10_6_1_07_ _ _ _ _ __ has resulted in the following civil penalty assessment of: Penalty Amount Due ..................................... _ _ _ _ _ _ _ _ _ _ _ _ __.:$!.c1~5~0~.0~0 Less Payment(s} Received ................................ _ _ _ _ _ _ _ _ _ _ _ _ _ _.--:!$~1:::.5::::0-~0.:::.0 BALANCE DUE .. ....................................... _ _ _ _ _ _ _ _ _ _ _ _ _....:$e.::O.:.:.Oc::.O Send the enclosed copy of this notice and your payment to the address shown below within 10 days. MAKE CHECKS PAYABLE TO THE CALIFORNIA DEPARTMENT OF SOCIAL SERVICES. Please write your invoice and facility number(s} on your check. Department of Social Services Community Care Licensing 3737 Main Street, Suite 700 Riverside, CA 92501 FAILURE TO PAY CIVIL PENALTY MAY RESULT IN ANY OR ALL OF THE FOLLOWING: • SMALL CLAIMS COURT ACTION • LICENSE DENIAL, SUSPENSION, OR REVOCATION • SEIZURE OF PERSONAL INCOME TAX REFUNDS STATE OF CAUFORN!A -HEALTH AND HUMAN SERVICES AGE CAUFORN!A DEPARTMENT OF SOCIAL SERVICES CIVIL PENALTY LEDGER PAYMENT, REDUCTION, OR WAIVER RECORD INVOICE N0.-'-09-'-0_18_9_9_ _ _ _ _ _ _ __ DISTRICT OFFICE NUMBER 09/H309 FAC!Ull' NAME Rancho Heritage School 2007/2008 FAC!UTY ADDRESS Rancho Cucamonga 84030 850 ZIP CODE STATE CA 08/12/2011 FACJUTY PCA CODE FAC!UTYTYPE 9488 Nineteenth Street CrTY 1DATE UC 422 SENT FISCAL YEAR 91701 IFACIUTY NUMBER UCENSEE(S) I 364809858 Rancho Heritage School ADDRESS 9235 Baseline Road CrTY Rancho Cucamonga ZIP CODE STATE CA 91701 DATE AMOUNT CUMULATIVE BALANCE Original Invoice Amount 09/06/07 $150.00 $150.00 8/12/11ck0005614470 $150.00 $0.00 $0.00 $0.00 Civil Penalty Waiver Penalty Review Reduction Penalty Review Reduction Payment 1 Payment2 PaymentS Payment4 Payment 5 BALANCE COMMENTS: I I STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICE COMMUNITY CARE LICENSING DIVISION CASH STATE RECEIPT FOR FEE TYPE PAID: CIVIL PENALTY THESE FEES ARE NON-REFUNDABLE FACILITY NUMBER REMITIER PCA PAY TYPE DATE OF CHECK CHECK NUMBER TOTAL AMOUNT COLLECTED 364809858 Rancho Heritage School 84035 Check 08/1212011 0005614470 $150.00 RECEIPT NO: DATE ISSUED: OFFICE: R09-000206251 08/1212011 09 ~ ... ·-·-···-··-- ·-------·----~- e:oc;w.. -"X_.._....."""'""" .. fhln.An4(M• "100 t:Al.WORHiA DIPitRT1IEJlT Of' GaMCSS ltlr.nd &nplrtCC. :mT ~ Ca.CAt2501 0010612007 • - · • ~ 94ll8 NINETEENTH STREET 91701 LICil iFACIUTYN._ RANCHO HERITAGE SCHOOL LICENSED FACIUTY CMI penalt!H can be auessed egalnllt any facllit)l which failS to take COfTeCilv& adion w!lhln prellC!ibed time periods, per California Health end &moly Code Sedlono15411, 15611.0822, 1568.49, end 1568.99. You are hereby notilled !hat a civil penalty has been !1&9SI!oed. Th& above filcility has bean fotlnd in violation oftho Collfomia Code of Regulation•. Tille 22, DMslons 6, and/or 12. Saction(3l 1Q121B.3 torufll)r California Heal!h and Safely Code. Chapters 3. 3.01. 3.2, 3.4. and 3.5 Sectfon(s) A Facllit)l Evaluation Repon (LIC 009} was issued on 091001201l7 giving ncti<>o that mil""" to cormct ths above viol!il!on(s) would msu~ in:; civil penalty. . BeoollSe you flliiad ro make !he corraellonc speciliad on the LIC 309, a civll penally of ~ I• as•e••ed for lh& U • pmod from lhrwgll . O,Aciv!J penalty of$50 per violation per day, up toe rna> civll penally of $15-~ per violntioo ihen $150 por dcr; per VtOfatioo tmtil OOt'!'edions are made. :·;, V!olaflons whic11 roll!JM in injury, olel made. STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY NOTICE OF CIVIL PENALTIES DUE iii INVOICE NO. 0 Initial Invoice 0902758 Final Notice DISTRICT OR COUNTY OFFICE NUMBER 09 I H309 ~----------·---------------- FAClLrTY NAME FISCAL YEAR Rancho Heritage School ________________ _ FACILITY ADDRESS 9488 19th Street ..:.:_ _ _ _ _ _ _s=TATE-~------'ztPCOOE cnY 201112012 FACILITY TYpe-- Rancho Cucamonga CA 91701 850 FACILITY NUMBER t364809858 LICENSEE{$) OR UNLICENSED FACILITY OPERATOR Rancho Heritage School ADDRESS DATE 09/22111 9488 19th Street CITY ZIP CODE STATE Rancho Cucamonga CA 91701 Licensin_g_P_ro_g_ra_m_::M:::a:::n:.::a:o>g=e:...r:_I_ _ ___] The California Health and Safety Code, Sections 1548, 1568.0822, 1569.49, 1596.99, and 1597.62 provides for the imposition of civil penalties against any facility which fails to take corrective action within prescribed time periods. The California Health and Safety Code, Sections 1547, 1568.0821, 1569.485, 1596.89, 1596.891 and 1597.61 provides for the imposition of civil penalties against any unlicensed facility which fails to take corrective action within prescribed time periods. The California Health and Safety Code, Sections 1522, 1568.09, 1569.17, 1596.871, and 1596.8712 provides for the imposition of immediate civil penalties against any facility which fails to comply with fingerprinting or other criminal background requirements. Your facility has been found in violation of Community Care Licensing statutes and regulations. Failure to correct the deficiency(ies) cited on the Licensing Report (LIC 809 or LIC 9099) dated,_0_9_10_1_1_1_1_~----­ has resulted in the following civil penalty assessment of: Penalty Amount Due ......... : ........................... -----------------'$~3~0:::0::_.0~0 Less Payment(s) Received ................................ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____:$:oo:O::.·-".:::OO BALANCE DUE ......................................... _ _ _ _ _ _ _ _ _ _ _ _ __:$~3~0~0.:.':.0~0 Send the enclosed copy of this notice and your payment to the address shown below within 10 days. MAKE CHECKS PAYABLE TO THE CALIFORNIA DEPARTMENT OF SOCIAL SERVICES. Please write your invoice and facility number(s) on your check. Department of Social Services Community Care Licensing 3737 Main Street, Suite 700 Riverside, CA 92501 FAILURE TO PAY CIVIL PENALTY MAY RESULT IN ANY OR ALL OF THE FOLLOWING: • SMALL CLAIMS COURT ACTION • LICENSE DENIAL, SUSPENSION, OR REVOCATION • SEIZURE OF PERSONAL INCOME TAX REFUNDS 422 (3102) (PUBLIC) STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY CALIFORWA DEPARTMENT OF SOCIAL SERVICES CIVIL PENALTY LEDGER PAYMENT, REDUCTION, OR WAIVER RECORD INVOICE N0. _ _:0.:.:90:.::2~75:.::8_ _ _ _ _ _ _ __ DISTRICT OFFICE NUMBER 091 H309 FACILITY NAME Rancho Heritage School __ 09_~_21~11~"~~----~ 2011/2012 FACILITY ADDRESS FACILITY TYPE 9488 19th Street FACILITY PCA CODE 84035 850 CITY STATE Rancho Cucamonga CA ZIP CODE 91701 UCENSEE{S) IFACIUTY NUMBER Rancho Heritage School I 364809858 ADDRESS 9488 19th Street ZIP CODE STATE CITY Rancho Cucamonga .. CA ----·- 91701 .. - .. - DATE . . ... ____ 6_MO!J.tiT_ ____ ___Q!JMULATJY_E_BAI,.AI\[gL Original Invoice Amount 09101111 Civil Penalty Waiver Penaity Review Reduction $300.00 $300.00 ---- ---·-~ ----------------- . --··- ----~- Penalty Review Reduction Payment 1 --- ·------ ~------------ . Payment 2 Payment 3 Payment 4 Payment 5 BALANCE $300.00 COMMENTS: uc 422A (5101) $300.00 STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES CIVIL PENALTY ASSESSMENT-- IMMEDIATE $150 i FACILIW NAME Rancho Heritage School FAcilfiYAOOReSS______ · - ~- ----- · -- - --- - DATE I 09/01/2011 ___ziPCi:JDE ______ _ ~-cm-------~---------~----Tswe ~468 19th srr:_:=~- _____________________Lf:ancho c':"."~~nga__________j-~~--_j_:~~_1_ ______ _ , UCENSEE(S) Rancho Herilage Scl1ool 1 --- FACIL~· / / / - o~~e'f" J b '"r"'o-i' ~ f A Licensing Report (UC 809 or LIC 9099) was issued on -=0=9/:.::0_:_1/:.::2:::0_:_11'----- giving notice I hal your facility has been found in DATE violation of one or more requirements for wl1ich an immediate civil penalty is warranted in accordance with one or more of the following California Health and Safety Code Sections: 1548,1568.0822, 1569.49, 1596.99 and 1597.58. You are hereby notified thai an immediate civil penalty of $150 per violation followed by $150 per day per violation until corrected is assessed for the period of 09/01/2011 through for the following violations: D~E D~E ['] Violations which result in injury, sickness or death of a client in care. (Does not apply to Residential Care Facilities for the Chronically Ill or Foster Family Homes.) l] Fire clearance violations (Does not apply to Family Child Care Homes.) ~ Absence ol supervision [J Accessible bodies of water lJ Accessible firearms, ammunition, or both [J Licensing agent refused entry to a facility or any part of a facility 0 The presence ol an excluded person on the premises Total# of (Per Day ) Violations: X $150 $ ---- Total Penalty Assessed YOU WILL RECEIVE AN INVOICE IN THE MAIL. DO NOT SEND MONEY UNTIL YOU RECEIVE YOUR INVOICE NAME OF LICENSING PROGRAM ANALYST UC421C {7/11) SIGNATURE OF LICENSING PROGRAM ANALYST I DATE PAGE1 OF2 STATE OF CALIFORtJIA ·HEALTH AND HLHMN SERVICES AGEI~CY CIILIFCflNIA DEI>AFITMENT OF SOCIAL SERVICES CIVIL PENALTY ASSESSMENT FAGIUTYim.-tE ___ · - - - - - - - - - · · ------------ - ·1 J Rancho Heritage School FA6ii.JTvAi50RESS - - - - - - - - - - - - - · - - - - - - - - - - - - - - - - l loill"' _______ - - - - - - - - - - - - - - - - - - l__o_s~01/2011_- --------------------- I 9488 19th Street ~a~~h~ Cucamo~ga, C~~;7:ic______________ '"'coo•· 0 UCE/IsEETsYor>EAAT~-'--~=-'-="-=---- Rancho Heritage School -- ·- . ·- --- ------, · ·-~~FACiti'iY~- ~---=---==~:.:.. · 364809858 _, _ _ _ _ _ _ _ _ _ _ _ _ __t__::::_: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ LICENSED FACILITY Civil penallies can be assessed against any facility which fails to take corrective action within prescribed time periods, per California Health and Safety Code Sections 1548, 1568.0822, 1569.49, 1596.99, and 1597.58. You are hereby notilied that a civil penally has been assessed. · The above facility has been found in violation of the California Code of Regulations, Tille 22, Divisions 6, and/or 12, Section(s) ...JJUZWLlJ(a)c__ _. . . . . . . , - - - - - - - - - - - - - - - - - - - - - - - - - - - - and/or California Heallh and Safety Code, Division 2, Chapters 3, 3.01, 3.2, 3.4, and 3.5, and 3.6. Section(s) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ A Licensing Report (LIC 809 or LJC 9099) was issued on _ _ _ _ ___,1-<-2,../0~7~/2,;'0"-JO.,______ giving notice that failure .to 0 correct the above violalion(s) would result in a civil penally. 'T' rl Because you failed to make the corrections specified on the LIC 809, a civil penally of$ ______ is assessed lor the period from through - - - = , - - DATE DATE LJ A civil penally of $50 per violation per day, up to a maximum of $150 per violation per day will be assessed. This will continue until correction(s) is made to comply with the licensing laws, regulations, and approval or the California Department of Social Services or authorized licensing agency. !Zl Because you repeated a violation of the same subsection within a 12-monlh period, an immediate civil penally of 150 oo is assessed for the period from 09/01/2011 through------=-=---$ 01\TE DATE 0 All Facility Types Except Child Care Centers: Second citation within a 12 month period; an immediate civil penally of $150 per violation; then $50 per day per violation until corrections are made. 0 Child Care Centers Only: Second citation within a 12-month period; an immediate civil penalty of $150 per violation; then $150 per day per violation until corrections are made. U Residential Care Facility for the Elderly (RCFE), Residential Care Facility for the Chronically Ill (RCF-CI): Third citation within a 12-mont11 period; an immediate civil penalty of $1,000 per violation; then $100 per day per violation until corrections are made. lJ Family Child Care Home (FCCH), Child Care Center (CCC), Community Care Facility (CCF): Third citation within 12month period; an immediate civil penalty of $150 per violation; then $150 per day per violation until corrections are made. l] FCCH and CCC only: Second or subsequent violation for failure to allow parent or guardian to enter and inspect facility or for retaliation/discrimination stemming from a request to enter or lodge a complaint A civil penalty of $50 per violation. Total Penalty Assessed $_ _ _ _ _ _ _ __ YOU WILL RECEIVE AN INVOICE IN THE MAIL. DO NOT SEND MONEY UNTIL YOU RECEIVE YOUR INVOICE f-~AME OF LICENSING PROGRAM JI.NALYST Kim Leung STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FACILITY EVALUATION REPORT CCLD Regional Office, 3737 MAIN ST., SUITE 700 RIVERSIDE, CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL ADMINISTRATOR:MASTANEH HAZEGH ADDRESS: 948819TH STREET CITY: RANCHO CUCAMONGA CAPACITY: 85 TYPE OF VISIT: Case Management Hal Hazegh MET WITH: FACILITY NUMBER: FACILITY TYPE: TELEPHONE: STATE:CA ZIP CODE: CENSUS: 24 DATE: UNANNOUNCED TIME BEGAN: TIME COMPLETED: 364809858 850 (909) 483-8250 91701 09/01/2011 08:25AM 10:55 AM NARRATIVE 1 LPA Kim Leung visited the facility conducting complaint investigation. During visit, LPA reviewed children's 2 records and found an incident report in file documented that a child was left alone on the playground in the afternoon on 7/19/2011 after outdoor activities. It was disclosed that after outdoor activities, teacher escorted 3 the children back to the activity room from the playground and was not aware of missing one child from the 4 group until another staff member stepped in the room to take census. It was disclosed that the child was 5 found alone on the playground after approximately 3 to 5 minutes. 6 7 8 See LIC809D for deficiency cited per California Code of Title 22, Division 12. 9 10 An exit interview was conducted, appeal rights discussed, Notice of Site Visit was posted and must stay 11 posted for 30 days. A copy of this report was provided. Upon receipt, licensee shall post and provide 12 copies of this licensing report to parents/guardians of children in care at the facility and to 13 parents/guardians of children newly enrolled at the facility during the next 12 months. A Fact Sheet of 14 AB633 and LIC9224 were provided to facility during visit. 15 16 A copy of this report must be made available for 3 years for public review upon request. 17 18 19 20 21 22 23 24 25 TELEPHONE: (951) 782-4200 SUPERVISOR'S NAME: Marianne Donley LICENSING EVALUATOR NAME: Ki Ying Kim Leung TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2011 I acknowledge receipt of this form and understand my licensing appeal rights as explained and receivedFACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2011 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC809 {FAS) • {06/04) Page: 1 of3 STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSING DMSION FACILITY EVALUATION REPORT (Cont) CCLD Regional Office, 3737 MAIN ST., SUITE 70D RIVERSIDE, CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL DEFICIENCY INFORMATION FOR THIS PAGE: FACILITY NUMBER: 364809858 VISIT DATE: 09/01/2011 Deficiency Type POC Due Date I DEFICIENCIES PLAN OF CORRECTIONS(POCs) Section Number Type A 09/01/2011 Section Cited 101229(a)(1) 1 2 3 4 5 6 7 1 2 3 4 specified in sections 101216.2(e)(1) and 5 101230(c)(1). A child was left alone on the playground on 7/19/2011 after outdoor activities. II 6 7 was disclosed that after outdoor 8 9 10 11 12 13 14 activities, teacher and children back to the activity 8 submit proof of training with staff signatures as 9 proof of correction. room from the playground and was not aware of missing one child from the group until another staff 10 11 member stepped in the room to take census. It was disclosed that the child was found alone on the 12 13 playground after approximately 3 to 5 minutes. Care and Supervision. No child{ren) shall be left without the supervision, including visual observation, of a teacher at any time except as An immediate civil penalty of $150 per day will be assessed. Facility was cited for lack of supervision on 1217/2010. Progressive civil penalty will be assessed. The employee has completed Child Care Center Orientation Component Ill on 8/18/2011. Licensee will provide training to all staff on supervision and 14 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 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: Marianne Donley TELEPHONE: (951) 782-4200 LICENSING EVALUATOR NAME: Ki Ying Kim Leung TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: DATE: 09101/2011 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 0910112011 This Notice must be posted for 30 days UC809 (FAS)· (06/04) · Pago: 2 of3 STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CAUFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DMSION FACILITY EVALUATION REPORT (Cont) CCLD Regional Office, 3737 MAIN ST., SUITE 700 RIVERSIDE, CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL DEFICIENCY INFORMATION FOR THIS PAGE: FACILITY NUMBER: 364809858 VISIT DATE: 09/01/2011 Deficiency Type POC Due Date I Section Number Type B 09/0212011 Section Cited 101212(d) PLAN OF CORRECTIONS(POCs) DEFICIENCIES 1 2 3 4 5 6 7 1 Licensee will submit written unusual incident report 2 to CCL by 9/2/2011. occurrence of any unusual incident as specified. A 3 child was left alone on the playground on 7/19/2011 4 1 2 3 1 2 3 4 4 5 6 Reporting Requirements. A report shall be made to the Department within 24 hours of the after outdoor activities. Licensee failed to report the 5 6 incident to Licensing as required. 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 7 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 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: Marianne Donley TELEPHONE: (951) 782-4200 LICENSING EVALUATOR NAME: Ki Ying Kim Leung TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2011 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2011 UC809 (FAS)· (06/04) Page: 3 of3 S ATE OF CALIFORNIA- HEALTH At:oficiency Vias cited. ~,All Facility Types: Second citation within a 12 month period: an immediate civil penalty of $150 per violation then $50 peT day per violation until corrections are made. =:',Residential Care Facility for the Elderly (RCFE), Residential Care Facility for the Chronically ILL (RCF-CI): Third +;:;itatkm within 12 month pet\od: an immediate civi\ pena!t;- of $1 ,000 per vie>!ation then $100 per day per violation t.!!itil corrections are made. i!, Family Child Care Homes (FCCH), Child Care Centers (CCC), Community Care Facility (CCF): - Third ~;itation within 12 month period; an immedfate civil pena!ty of $150 per violation then $150 per day per ·..iotaf.on t.m'i:il ccrrectiom; are made. ' !, Violations which result in injurJ, sickness, or death An immediate civil penalty of $150 per vioation and then $150 per day per violation until coiTections are made. YOU WILL RECE!VE A BILL IN THE !\IL.O.JL. DO NOT SEND MONEY UNTIL YOU RECEIVE YOUR BILL\ NAME OF LICENSING PROGP..Af,.-, Al'.lAL YST Ki Ylng Kim Leung SIGNATURE OF UCENS~NG PROGRAivi ANALYST NMJ!E OF FACILITY REPRESENTATIVEffiTLE Hal He2egh, Licensee DATE 05/30/2008 TITLE UC421 (FAS)·(OS/06) Page: 1 of 2 STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES A CALIFORNIA OEPARTMEtfr OF SOCIAL SERVICES CIVIL PENALTY LEDGER PAYMENT, REDUCTION, OR WAIVER RECORD INVOICE N0._:0.:::90::2.:::08:_:4_ _ _ _ _ _ _ _ __ DISTRICT OFFICE NUMBER 09H405 FACILITY NAME FISCAL YEAR ! Rancho Heritage School 2007/2008 FACILITY ADDRESS FAClUlY TYPE I 9488 Nineteenth Street Rancho Cucamonga CA 06/12/08 FACILITY PCA CODE 84030 850 ~c;IIT~~~~~~~~~---~s~~~,E~-------~~~Pc~o"'o~ DATE LIC 422 SENT I 91701 1';~~~;~~8 LICENSEE(S) Rancho Heritage School I ADDRESS 9235 Baseline Road CIIT Rancho Cucamonga STATE CA ZIP CODE 91701 I I AMOUNT DATE CUMULATIVE BALANCE Original Invoice Amount 05/30/08 $150.00 $150.00 $150.00 $150.00 Civil Penalty Waiver Penalty Review Reduction Penalty Review Reduction I I I II II I I I I I Payment 1 Payment 2 Payment 3 I' I I Payment 4 I I I I I I Payment 5 I I BALANCE I COMMENTS: uc 422A (5101} STATE OF CAUFORNIA ~HEALTH AND HUMAN SERVICES AGENCY CAUFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING OMSION Inland Empire CC 3737 Main Atreet Suite 700 Riverside, Ca, CA 92501 06/02/2008 RANCHO HERITAGE SCHOOL 364809858 9235 BASELINE ROAD RANCHO CUCAMONGA, CA 91730 Letter of Deficiency Citations Cleared Dear Licensee, The following deficiencies, initially cited during a visit on 05/30/2008, have been cleared: Section Cited: 101216.3(a) Date Due: 05130/2008 Plan of Correction: Corrections: Clearance Date: Ucensee will submit written statement detailing how the deficiency has been corrected. Licensee submitted written statement and staffing plan. 05/30/2008 LICENSING EVALUATOR NAME: Ki Ying Kim Leung TELEPHONE: (951) 529-•1713 LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2008 This report must be available at Child Care and Group Home facilities for public review for 3 years. Cleared POC Letter (FAS) • (04f05) Page: 1 of 2 STATE OF CALIFORNIA ~HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSING DIVISION Inland Empire CC 3737 Main Atreet Suite 700 Riverside, Ca, CA 92501 06/02/2008 RANCHO HERITAGE SCHOOL 364809858 COMMENTS Please be advised of the following requirement per California Health & Safety Code: Per Section 1596.8595(b} the licensee shall post the "Letter of Deficiency Citations Cleared" verifying the licensee's compliance or noncompliance with the department's order (LIC809D or LIC 9099D) to correct a type A deficiency that is subject to posting for a period of 30 days. The "Letter of Deficiency Citations Cleared" shall be posted immediately upon receipt, immediately adjacent to, the interior side of the main door into the facility and shall be posted for a period of 30 consecutive days. Failure to comply shall result in an immediate civil penalty of one hundred dollars ($100). LICENSING EVALUATOR NAME: Ki Ying Kim Leung TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2008 This report must be available at Child Care and Group Home facilities for public review for 3 years. Cleared POC Letter (FAS) ~ (0611)4) Page: 2 or 2 STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSING DIVISION FACILITY EVALUATION REPORT Inland Empire CC, 3737 Main Atreet Suite 700 Riverside, Ca, CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL ADMINISTRATOR: MASTANEH HAZEGH ADDRESS: 9488 NINETEENTH STREET CITY: RANCHO CUCAMONGA CAPACITY: 85 TYPE OF VISIT: Case Management Hal Hazegh MET WITH: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 FACILITY NUMBER: FACILITY TYPE: TELEPHONE: STATE:CA ZIP CODE: CENSUS: 39 DATE: UNANNOUNCED TIME BEGAN: TIME COMPLETED: 364809858 850 {909) 483-8250 91701 05/30/2008 08:50AM 01:00PM NARRATIVE LPA Kim Leung visited the facility conducting a complaint investigation. Upon arrival, LPA observed a staff taking 16 children by herself to the playground. LPA observed an assistant joining the group when the children were leaving the building to the playground. During visit, LPA obtained information that the facility has operated out of teacher-child ratio with one teacher supervising more than 12 children during transition time. An exit interview was conducted, appeal rights discussed, Notice of site Visit was posted, and a copy ofthis report was provided. Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. A Fact Sheet of AB633 and LIC9224 were provided to facility during visit. SUPERVISOR'S NAME: Tammy J. McMichael-Peirce TELEPHONE: {951) 782-4970 LICENSING EVALUATOR NAME: Ki Ying Kim Leung TELEPHONE: {951) 529-4713 LICENSING EVALUATOR SIGNATURE: DATE: 05/30/2008 t acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: ~ DATE: 05/30/2008 This report must be available at Child Care and Group Home facilities for public review for 3 years. UC809 (FAS)- (06104) Page: 1 of3 STATE OF CALIFORNIA. HEALTH AND HUMAN SERVICES AGENCY CAUFORNIA DEPARTMENT OF SOCIAL SERVlCES COMMUNITY CARE UCENSING DIVISION FACILITY EVALUATION REPORT (Cont) Inland Empire CC, 3737 Main Atret!t SUite 700 RIV«Side, Ca, CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL DEFICIENCY INFORMATION FOR THIS PAGE: Deficiency Type POC Due Date I FACILITY NUMBER: 364809858 VISIT DATE: 05/30/2008 PLAN OF CORRECTIONS(POCs) DEFICIENCIES Section Number Type A 05/30/2008 Section Cited 101216.3(a) Section Cited 1 Teacher-Child Ratio. Facility had one teacher 2 supervising more than 12 children without an 3 assistant on several occasions during transition 1 Licensee will submit written statement detailing 2 how the deficiency has been corrected. 3 4 time. LPA observed a staff taking 16 children by 4 5 herself to the playground. Facility was cited for the 5 6 6 same deficiency on 9/6/2007. Progressive civil 7 7 penalty will be assessed. 1 2 3 1 2 3 4 4 5 6 7 5 6 7 1 1 2 3 4 5 6 7 2 3 Section Cited 4 5 6 7 1 2 3 Section Cited 4 5 6 7 1 2 3 4 5 6 7 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: Tammy J. McMichael-Peirce TELEPHONE: (951) 782-4970 LICENSING EVALUATOR NAME: Ki Ying Kim Leung TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: ~~~ DATE: 05/30/2008 I acknowledge receipt of this fonn and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: ~ DATE: 05/30/2008 This Notice must be posted for 30 days LIC809 (FAS}- (O&J04) Page:2of3 STATE OF CALIFORNIA· HEALTH AND HUMAN SERV1CES AGENCY CAUFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSING D!VlSION COMPLAINT INVESTIGATION REPORT (Cont) Inland Empir& CC, 3737 Main Atreet Suite 700 Rlver'#lde, Ca, CA 92501 This is an official report of an unannounced visit/investigation of a complaint received in our office on 05/27/2008 and conducted by Evaluator Ki Ying Kim Leung · PUBLIC COMPLAINT CONTROL NUMBER: 09-CC-20080527095132 FACILITY NAME: RANCHO HERITAGE SCHOOL ADMINISTRATOR:MASTANEH HAZEGH ADDRESS: 9488 NINETEENTH STREET CITY: RANCHO CUCAMONGA CAPACITY: 85 MET WITH: Hal Hazegh STATE: CENSUS: 39 ANNOUNCED FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: 364809858 850 (909) 483-8250 91701 05/30/2008 08:50AM 10:07 AM ALLEGATION(S}: 1 Qualifications- Unqualified staff 2 3 Physical Plant- Unsafe accommodations 4 5 Physical Plant- Water availability 6 7 8 9 INVESTIGATION FINDINGS: 1 LPA Kim Leung visited the facility conducting a complaint investigation. Upon arrival, met with director 2 Mastaneh Hazegh and took census. During the visit, LPA talked with licensee Hal Hazegh, toured the facility, 3 reviewed roster, attendance records and transcripts. Interviews with staff were conducted. On the playground, 4 LPA and licensee observed that the faucet of only drinking fountain was turned off. At the back of the building, 5 LPA and licensee observed a significant amount of bees flying around a light pole. Licensee stated that they 6 had pest control company to spray the light pole and last it was sprayed was approximately 6 months ago. 7 Licensee stated that it was observed that bees started flying around the light pole again approximately 3 weeks 8 ago. LPA and licensee also observed a broken window in Room 108 where accessible to children. Licensee 9 stated that the window has been cracked for approximately 3 weeks but he was not reported to until 5/29/2008. 10 Licensee stated that arrangement has been made to replace the window this weekend. LPA observed that 11 tape and poster paper over the cracked window. Per transcripts review, staff #1 has not completed the core 12 units and there's no proof of enrollment on file. Therefore, staff #1 is not teacher-qualified but it was disclosed 13 that staff #1 is hired as a teacher and Substantiated Estimated Days of Completion: SUPERVISOR'S NAME: Tammy J. McMichael-Peirce TELEPHONE: (951) 782-4970 LICENSING EVALUATOR NAME: Ki Ying Kim Leung TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: DATE: 05/30/2008 I acknowledge receipt of this fonn and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: ~ /l"'-1rL....~ DATE: 05/30/2008 This report must be available at Child Care and Group Home facilities for public review for 3 years. Control Number 09-CC-20080527095132 STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION COMPLAINT INVESTIGATION REPORT (Cont) Inland Empire CC, 3737 Main Atroot Suite 700 Riverside, Ca, CA 92501 FACILITY NUMBER: 364809858 VISIT DATE: 05/30/2008 FACILITY NAME: RANCHO HERITAGE SCHOOL NARRATIVE 1 2 3 4 5 6 7 has supervised children by herself. Information gathered during visit supports the allegations. Thiscomplaint is therefore substantiated. An exit interview was conducted, appeal rights discussed, Notice of site Visit was posted, and a copy of this report was provided. Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. A Fact Sheet of AB633 and LIC9224 were provided to facility during visit. 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 SUPERVISOR'S NAME: Tammy J. McMichael-Peirce TELEPHONE: (951) 782-4970 LICENSING EVALUATOR NAME: Ki Ying Kim Leung TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: DATE: 05/30/2008 I acknowledge receipt of this fonn and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: ~ LIC9099 (FAS)- (06104) DATE: 05/30/2008 Page: 1 of 2 Control Number 09-CC-20080527095132 STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DMS!ON COMPLAINT INVESTIGATION REPORT (Cont) Inland Empire CC, 3737 Main Atreet Suite 700 Riverside, ca, CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL DEFICIENCY INFORMATION FOR THIS PAGE: FACILITY NUMBER: 364809858 VISIT DATE: 05/30/2008 Deficiency Type POC Due Date I DEFICIENCIES PLAN OF CORRECTIONS(POCs) Section Number Type A 06/0212008 Section Cited 101216.1(b) 1 Teacher Qualifications and Duties. Staff#1 who is 2 not teacher-qualified is hired as a teacher and has 3 supervised children by herself. 4 5 6 7 1 2 3 4 5 6 7 Licensee stated that staff schedule would be rearranged and the staff would be an aide working with a qualified teacher, effective immediately. Staffing plan will be submitted by next business Type A 06/0212008 Section Cited 101239.2(a) 1 2 3 4 5 6 7 Drinking Water. The faucet of the only drinking fountain on playground was turned off. Drinking water must be readily available indoor and outdoor at all times. 1 2 3 4 5 6 7 licensee has turned on the faucet during visit to correct the deficiency. Licensee will ensure that drinking water be always readily available to children. Type A 06/0212008 Section Cited 101238(a) 1 2 3 4 5 6 7 Building and Grounds. LPA observed a significant amount of bees flying around a light pole at the back of the building. That presented immediate risk to children's safety. 1 2 3 4 5 6 7 licensee will schedule pest control company to apply treatment. Invoice and written statement will Section Cited 1 2 3 4 5 6 7 day on 6/212008. be submitted to CCL by 61212008 as proof that the bee problem has been resolved. 1 2 3 4 5 6 7 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: Tammy J. McMichael-Peirce TELEPHONE: (951) 782-4970 LICENSING EVALUATOR NAME: Ki Ying Kim Leung TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: DATE: 05/30/2008 I acknowledge receipt of this fonn and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: ~ DATE: 05/30/2008 This Notice must be posted for 30 days UC9099 (FAS)- (06104) Page: 2 of2 Control Number 09-CC-20080527095132 STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CAUFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DMSION COMPLAINT INVESTIGATION REPORT (Cont) Inland Empire CC, 3737 Marn Atreet Suite 700 Riverside, Ca, CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL DEFICIENCY INFORMATION FOR THIS PAGE: FACILITY NUMBER: 364809858 VISIT DATE: 05/30/2008 Deficiency Type POC Due Date I Section Number DEFICIENCIES PLAN OF CORRECTIONS(POCs) TypeS 06/02/2008 1 Building and Grounds. LPA observed a broken 2 window in Room 108 where accessible to children. 3 The window was taped and covered with poster 4 paper. 5 6 7 1 Licensee will replace the window and submit 2 invoice and written statement to CCL by 6/212008. 3 4 5 6 7 1 2 3 1 2 3 4 5 6 7 4 5 6 7 1 2 3 4 5 6 7 1 2 3 1 2 3 1 2 3 4 5 6 7 Section Cited 101238(a) Section Cited Section Cited Section Cited 4 5 6 7 4 5 6 7 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: Tammy J. McMichael-Peirce TELEPHONE: (951) 782-4970 LICENSING EVALUATOR NAME: Ki Ying Kim Leung TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: b»==--~'\ DATE: 05/30/2008 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/30/2008 UC9099 (FAS)- (06104) Page: 2 of2 STATE OF CAUFORNIA ·HEALTH AND HUMAN SERvtCES AGENCY CAUFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENIDNG DMSION FACILITY EVALUATION REPORT (Cont) Inland Empire CC. 3737 Main Atreet Suite 700 Rivemlde, Ca. CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL DEFICIENCY INFORMATION FOR THIS PAGE: FACILITY NUMBER: 364809858 VISIT DATE: 05/30/2008 Deficiency Type Tyn-P. 8 Oti;02i2008 SeCtion (;!r:e;:; 10123~:.1\C) \1 1Napping Equipment. LPA observed that napping !? j cots were stackeo up on top of each other with cot j ~ !sheets l1aving contact '-"'ith other cot sheets. I 1!submitted to CCL by 6!2!2008. l;:;; "' :r j6[ { i l1 i Pr-rc,-,.nn~! Rr.>f"nrrl.;; 121 ::!2 ;;-:~ 1012i7(a)(6} \3\ i '~ l 1 Licensee will provide in·service training to staff. ~~~ Proof of training and staff signatures will be ?l if i 06/(1'3f2008 PLAN OF CORRECTIONS(POCs) DEFICIENCIES POC Due Date 1 Section Number f'::'l!Ylr'.!Pt:.> tr::m:.,..rip+::: fnr St~ff ;!!:: :;;·~:-.; ;;-:·t ;·.:;:;~~;.;: 7:-;- ,~ ..:!.;:.;;,; -::::7;::;; ·~:;~ i 5! le;! i-, i i' i I.! ! i I ; j r i:-:~n~r>(' wm :.nhm!t r,;p~ tl"t r:r! h:r RiRt::'nrw ~~ '1[ ~~ Ji .I l ~~':~~~~ ..::::::!:::! I~ I 1 r( j i5 i i i: i ii Section Cited I 'i 1 1 2 3 2 3 4 4 5 6 6 7 7 i 5 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: Tammy J. McMichael-Peirce TELEPHONE: (951) 782-4970 LICENSING EVALUATOR NAME: Ki Ying Kim Leung TELEPHONE: (951) 529-4713 UCENSitJG EVALUATOR SiGNATURE: DATE: 05/30/2008 I acknowledge receipt of this fonn and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: ~ UC809 (FAS}- (06ro4} DATE: 05/30/2008 Page: 3 of3 STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CAUFORNIA DEPARTMENT OF SOCIAL SERVJCES COMMUNITY CARE UCENSitiG OMSION FACILITY EVALUATION REPORT Inland Empire CC, 3737 Main Atreet Suitu 700 Riverside, ca, CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL ADMINISTRATOR: MASTANEH HAZEGH ADDRESS: 9488 NINETEENTH STREET CITY: RANCHO CUCAMONGA 85 CAPACITY: TYPE OF VISIT: Case Management Hal Hazegh MET WITH: 1 2 3 4 5 6 7 8 9 STATE:CA CENSUS:31 UNANNOUNCED FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 364809858 850 (909) 483-8250 91701 03/20/2008 09:30AM 11:00AM NARRATIVE LPA Kim Leung arrived at the facility on a case management visit to follow-up on the unusual incident report submitted by the facility on 3/11/2007. At the time of visit, LPA toured the facility, took census, met with licensee Hal Hazegh to discuss the reported incident and reviewed records. During the visit, LPA also spoke with the Teachers who had supervised the subject child. The subject child involved in the incident has been withdrawn from the program prior to this visit and LPA therefore was not able t ointerview the child during visit. No information to support the alleged incident at this time. 10 11 12 13 14 15 An exit interview was held with licensee Mr. Hazegh. A Notice of Site visit was issued, along with a copy of this report. This report shall be public record for three years. 16 17 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME: Tammy J. McMichael-Peirce TELEPHONE: (951) 782-4970 LICENSING EVALUATOR NAME: Ki Ying Kim Leung TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2008 I acknowledge receipt of this fonn and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: Mf! DATE: 03/20/2008 This report must be available at Child Care and Group Home facilities for public review for 3 years. UC809 (FAS) • {06104) Page: 1 of1 STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES NOTICE OF CIVIL PENALTIES DUE 0 1i2i Final Notice DISTRICT OR COUNTY OFFICE NUMBER 09 (0773) Initial Invoice INVOICE NO. 0901899 FISCAL YEAR fACILITY NAME '2007/2008 Rancho Hertage School -FACILITY ADDRESs 10/22/07 FACiLiTY TYPE - - ------- 9235 Basline Road 850 Rancho Cucamonga ---- -·---------- 84030 ziPCOOE STATE 91701 Ca " 'FACILITY NUMBER - --------, Rancho Hertage School -Ao-DRess--·- -·· -- - -· - - --~--- 9235 Basline Road CITY STATE Rancho Cucamonga ---- ------- CA ZIP CODE 91730 The California Health and Safety Code, Sections 1548, 1568.0822, 1569.49, 1596.99, and 1597.62 provides for the imposition of civil penalties against any facility which fails to take corrective action within prescribed time periods. The California Health and Safety Code, Sections 1547, 1568.0821, 1569.485, 1596.89, 1596.891 and 1597.61 provides for the imposition of civil penalties against any unlicensed facility which fails to take corrective action within prescribed time periods. The California Health and Safety Code, Sections 1522, 1568.09, 1569.17, 1596.871, and 1596.8712 provides for the imposition of immediate civil penalties against any facility which fails to comply with fingerprinting or other criminal background requirements. Your facility has been found in violation of Community Care Licensing statutes and regulations. Failure to correct the deficiency{ies) cited on the Licensing Report (LIC 809 or LIC 9099) dated 9/6/07 has resulted in the following civil penalty assessment of: Penalty Amount Due .................................... . $150.00 Less Payment{s) Received ................................ _______ .JP..,OO BALANCE DUE. ....................................... . $150.00 Send the enclosed copy of this notice and your payment to the address shown below within 10 days. MAKE CHECKS PAYABLE TO THE CALIFORNIA DEPARTMENT OF SOCIAL SERVICES. Please write your invoice and facility number{s) on your check. Community Care Licensing 3737 Main Street, Suite 700 Riverside, CA 92501 FAILURE TO PAY CIVIL PENALTY MAY RESULT IN ANY OR ALL OF THE FOLLOWING: • SMALL CLAIMS COURT ACTION • LICENSE DENIAL, SUSPENSION, OR REVOCATION • SEIZURE OF PERSONAL INCOME TAX REFUNDS l!C ~22 (J/02) (PUBLIC) STATE OF CALIF"ORNIA- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES NOTICE OF ii2l ftl~Ee/t~ DUE D Initial Invoice DISTRICT OR COUNTY OFFICE NUMBER 09/077~--- INVOICE NO. 0901899___ -----· FACILITY NAME I, Rancho Hertage School · - · - - --- ------· IFACILITY ADDRESS 9235 Basline Road STATE CITY , Rancho Cucamonga Final Notice Ca i ·---1 ZIP CODE ------ 91701 I YEAR 2007/2008 i FACILITY TYPE 1850 DATE UC ~22.SENT 10/03/07 PENALTY PCA 84030 I rACILITY NUMBER ------ LICENSEE{S) OR UNLICENSED FACILITY OPERATOR IFISCAL 364809858 CODE =] __j Rancho Hertage School ADDRESS 9235 Basline Road ZIP CODE STATE CITY Rancho Cucamonga CA 91701 The California Health and Safety Code, Sections 1548, 1568.0822, 1569.49, 1596.99, and 1597.62 provides for the imposition of civil penalties against any facility which fails to take corrective action within prescribed time periods. The California Health and Safety Code, Sections 1547, 1568.0821, 1569.485, 1596.89, 1596.891 and 1597.61 provides for the imposition of civil penalties against any unlicensed facility which fails to take corrective action within prescribed time periods. The California Health and Safety Code, Sections 1522, 1568.09, 1569.17, 1596.871, and 1596.8712 provides for the imposition of immediate civil penalties against any facility which fails to comply with fingerprinting or other criminal background requirements. Your facility has been found in violation of Community Care Licensing statutes and regulations. Failure to correct the defrciency(ies) cited on the Licensing Report (LIC 809 or LIC 9099) dated_~6/07 ---------------has resulted in the following civil penalty assessment of: Penalty Amount Due ..................................... _______________________________ j_:I_§_Q_,_Q_Q_ Less Payment(s) Received ................................ _________________________________ j_9_,_QQ BALANCE DUE......................................... ________________________ j_1§_9_,_QQ Send the enclosed copy of this notice and your payment to the address shown below within 10 days. MAKE CHECKS PAYABLE TO THE CALIFORNIA DEPARTMENT OF SOCIAL SERVICES. Please write your invoice and facility number(s) on your check. Community Care Licensing -------------------------------------3737 Main Street, Suite 700 Riverside, CA 92501 FAILURE TO PAY CIVIL PENALTY MAY RESULT IN ANY OR ALL OF THE FOLLOWING: • SMALL CLAIMS COURT ACTION • LICENSE DENIAL, SUSPENSION, OR REVOCATION • SEIZURE OF PERSONAL INCOME TAX REFUNDS UC 422 (3102) (PUBLIC) STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY CALIFORtl!A DEPARTMENT OF SOCIAL SERVICES CIVIL PENALTY LEDGER PAYMENT, REDUCTION, OR WAIVER RECORD INVOICE N0 ..::_0::..:90:..:.18::..:9:.::.9_ _ _ _ _ _ _ _ __ DISTRICT OFFICE NUMBER 09/0773 FACILITY NAME [ ASCAL YEAR Rancho Heritage School FACILITY ADDRESS 10/3/07 FACILITY PCA CODE FACILITY TYPE 9235 Baseline Road CITY DATE LIC 422 SENT 2007/2008 84030 850 STATE ZIP CODE c_:_:R:.:a:.:.nc:.:h.::o:_C=uc:.:a:::m:.:.o:.:n.:;g,a:__ _ _ _.::C:_A: _ _____c9::_1:.:.7'-"-'01 _ _ __ j ~ LICENSEE($) Rancho Heritage School ADDRESS 9235 Baseline Road CITY Rancho Cucamonga STATE CA J ZIP CODE 91701 I Original Invoice Amount r~~~~;;~8 --- __L_.Q.L!MULATIVE BALANCE AMOUNT DATE - --, 10/3/07 $150.00 $150.00 I Civil Penalty Waiver ____ j I Penalty Review Reduction Penillty Review Reduction Payment 1 ·-- II ' I - -· --- --j I -~-- I Payment 2 I Payment 3 Payment 4 I Payment 5 I I BALANCE $150.00 'COMMENTS: I uc 422A {5101) - - $150.00 STATE OF CALIFORNIA~ HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIViSION CIVIL PENALTY ASSESSMENT Inland Empire CC, 3737 Main Atreet Suite 700 Riverside, Ca, CA 92501 DATE FACILITY NAME RANCHO HERITAGE SCHOOL 09/06/2007 CITY FACIUTY ADDRESS 9488 NINETEENTH STREET RANCHO CUCAMONGA STATE ZIP CODE UCENSEE(S)IOPERATOR FACILITY NUMBER 91701 RANCHO HERITAGE SCHOOL 364809858 LICENSED FACILITY Civil penalties can be assessed against any facility which fails to take corrective action within prescribed time periods, per California Health and Safety Code Sections 1548, 1568.0822, 1569.49, and 1569.99. You are hereby notified that a civil penalty has been assessed. The above facility has been found in violation of the California Code of Regulations, Title 22, Divisions 6, and/or 12, Section(s) 101216.3 and/or California Health and Safety Code, Chapters 3, 3.01, 3.2, 3.4, and 3.5 Section(s) A Facility Evaluation Report (LIC 809) was issued on 09/06/2007 giving notice that failure to correct the above violation(s) would result in a civil penalty. Because you failed to make the corrections specified on the UC 809, a civil penalty of $0.00 is assessed for the 0 ' period from through . D, A civil penalty of $50 per violation per day, up to a maximum of $150 per day will be assessed. This will continue until correction(s) are made to comply with the licensing laws, regulations, and approval of the California Department of Social Services or authorized licensing agency. [:gJ, Because you repeated a violation of the same subsection within a 12 month period ,an immediate civil penalty of$150.00 is assessed for 09/06/2007, the day the deficiency was cited. [:zl, All Facility Types: Second citation within a 12 month period; an immediate civil penalty of $150 per violation then $50 per day per violation until corrections are made. D, Residential Care Facility for the Elderly (RCFE), Residential Care Facility for the Chronically ILL (RCF-CI): Third citation within 12 month period; an immediate civil penalty of $1,000 per violation then $100 per day per violation until corrections are made. D, Family Child Care Homes (FCCH), Child Care Centers (CCC), Community Care Facility (CCF): Third citation within 12 month period; an immediate civil penalty of $150 per violation then $150 per day per violation until corrections are made. 0, Violations which result in injury, sickness, or death An immediate civil penalty of $150 per vioation and then $150 per day per violation until corrections are made. YOU WILL RECEIVE A BILL IN THE MAIL. DO NOT SEND MONEY UNTIL YOU RECEIVE YOUR BILL! NAME OF LICENSING PROGRAM ANALYST Ki Ying Kim Leung SIGNATURE OF LICENSING PROGRAM ANALYST NAME OF FACILITY REPRESENTATIVE/TITLE Mastaneh Hazegh, Director SIGNATURE OF FACILITY REPRESENTATIVE -~x/G SUPERVISOR REVIEW SIGNATURE (FOR INTERNAL USE ONLY) DATE 09/06/2007 TITLE UC421 (FAS)- (05100} Page: 1 of2 STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION Inland Empire CC 3737 Main Atreet Suite 700 Riverside, Ca, CA 92501 09/26/2007 RANCHO HERITAGE SCHOOL 364809858 9235 BASELINE ROAD RANCHO CUCAMONGA, CA 91730 Letter of Deficiency Citations Cleared Dear Licensee, The following deficiencies, initially cited during a visit on 09/06/2007, have been cleared: Section Cited: 101216.3 Plan of Correction: licensee will ensure thai proper teac11er..child ratio be maintained at allltmes. D1rector w1U submll staffmg schedule and children's childcare schedule to CCL. LICENSING EVALUATOR NAME: Ki Ying Kim Leung Date Due: 09/06/2007 Corrections: Received roster on 9/6/2007. Director resubmitted staff schedule on 9/21/2007 after phone follow up by LPA. Clearance Date: 09/06/2007 TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2007 This report must be available at Child Care and Group Home facilities for public review for 3 years. Cleared POC Letter (FA$)· {04/05) Page: 1 of 2 STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION Inland Empire CC 3737 Main Atreet Suite 700 Riverside, Ca, CA 92501 09/26/2007 RANCHO HERITAGE SCHOOL 364809858 COMMENTS Please be advised of the following requirement per California Health & Safety Code: Per Section 1596.8595(b) the licensee shall post the "Letter of Deficiency Citations Cleared" verifying the licensee's compliance or noncompliance with the department's order (LIC809D or LIC 9099D) to correct a type A deficiency that is subject to posting for a period of 30 days. The "Letter of Deficiency Citations Cleared" shall be posted immediately upon receipt, immediately adjacent to, the interior side of the main door into the facility and shall be posted for a period of 30 consecutive days. Failure to comply shall result in an immediate civil penalty of one hundred dollars ($1 00). LICENSING EVALUATOR NAME: Ki Ying Kim Leung TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: I /~~-----'--..... ~ ) DATE: 09/26/2007 This report must be available at Child Care and Group Home facilities for public review for 3 years. Cleared POC Lettor{FASJ- {06104) Page: 2 of 2 STATE OF CALIFORNIA~ HEALTH AND HUMAN SERVlCESAGENCY CAUFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSING DIVISION COMPLAINT INVESTIGATION REPORT Inland Empire CC, 3737 Main Atroet Suire 700 ruv&n~lde, ca, CA 92501 This is an official report of an unannounced visiUinvestigation of a complaint received in our office on 08/29/2007 and conducted by Evaluator Ki Ying Kim Leung PUBLIC COMPLAINT CONTROL NUMBER: 09-CC-20070829125943 FACILITY NAME: RANCHO HERITAGE SCHOOL ADMINISTRATOR:MASTANEH HAZEGH ADDRESS: 9488 NINETEENTH STREET CITY: RANCHO CUCAMONGA CAPACITY: 85 STATE: CENSUS: 13 UNANNOUNCED MET WITH: Mastaneh Hazegh FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: 364809858 850 (909) 483-8250 91701 09/06/2007 09:30AM 12:30 PM ALLEGATION(S): 1 Other - ratio 2 3 4 5 6 7 8 9 INVESTIGATION FINDINGS: 1 LPA Kim Leung visited the facility conducting a complaint investigation. LPA met with facility director Mastaneh 2 Hazegh, took census, interviewed children and staff. Sign in and sign records, and staff time cards were 3 reviewed. Per information obtained during visit. the facility was operating out of teacher-child ratio on several 4 days during the week of 8/27/2007 with only one teacher supervising more than 12 children without an 5 assistant after 4pm. 6 7 8 g Since information obtained support ttie allegation, this complaint is substantiated. An exit interview was conducted, appeal rights discussed, Notice of site Visit was posted, and a copy of this 10 report was provided. Upon receipt, licensee shall post and provide copies of this licensing report to 11 parents/guardians of children in care at the facilijy and to parents/guardians of children newly enrolled at the 12 facility during the next 12 months. A Fact Sheet of AB633 and LIC9224 were provided to facility during visit. 13 Substantiated Estimated Days of Completion: SUPERVISOR'S NAME: Tammy J. McMichael-Peirce TELEPHONE: (951) 782-4970 LICENSING EVALUATOR NAME: Ki Ying Kim Leung TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2007 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: f! DATE: 09/06/2007 This report must be available at Child Care and Group Home facilities for public review for 3 years. UC9099 (FAS) • (00104) Pa(J*: 1 of 2 Control Number 09-CC-20070829125943 STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCiAL SERVICES COMMUNITY CARE UCENSING DIVISION COMPLAINT INVESTIGATION REPORT (Cont) Inland Empire CC, 3737 Main Atreet Suite 700 Riverside, CD, CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL DEFICIENCY INFORMATION FOR THIS PAGE: Deficiency Type POC Due Date/ FACILITY NUMBER: 364809858 VISIT DATE: 09/06/2007 DEFICIENCIES PLAN OF CORRECTIONS(POCs) Section Number Type A 09/06/2007 Section Cited 101216.3 Section Cited 1 2 3 4 5 6 7 1 Licensee will ensure that proper teacher--child ratio Teacher-Child Ratio. Facility had one teacher 2 be maintained at all times. Director will submit supervising more than 12 children without an assistant on several afternoons during the week of 3 staffing schedule and children's childcare schedule 1 2 3 4 1 2 3 4 5 6 7 8/27/2007. Facility was cited for the same deficiency on 4/4/2007. Prognessive civil penalty will be assessed. 5 6 7 Section Cited 1 2 3 4 5 6 7 Section Cited 1 2 3 4 5 6 7 4 to CCL. 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 Failure to connect the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment SUPERVISOR'S NAME: Tammy J. McMichael-Peirce TELEPHONE: (951) 782-4970 LICENSING EVALUATOR NAME: Ki Ying Kim Leung TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: DATE: 09/0612007 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2007 This Notice must be posted for 30 days UC9099 (FAS) · (06104) Page: 2 of2 All POC Have Been Cleared STATE OF CAUFORNIA· HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DlVlSlON CLEARED DEFICIENCIES Inland Empire CC, 3737 Main Street Sulle 700 Riverside, CA 92501 FACILITY NUMBER: 364809858 VISIT DATE: 05/25/2007 FACILITY NAME: RANCHO HERITAGE SCHOOL POC Due Date I Section Number 05/29/2007 101229(a)(1) Date Cleared I Comments PLAN OF CORRECTIONS(POCs) 1 2 Facility will provide an in-service training to all staff regarding 3 Section 101229, Responsibility for Providing Care and 1 2 0513012007 4 Supervision which should include visual supervision of children Cleared 5/29/07 3 5 tall times. Facility to submit a sign-in sheet of employees 4 6 who attended and what was discussed by 5/29/07. 7 05/29/2007 Section Cited 101216.2(e) 1 2 3 4 5 6 7 Facility will provide an in-service training to all Teacher's egarding Section 101216.2(e) and discuss how Aides shall work under the direct supervision of a fully qualified Teacher. Facility to submit a sign-in sheet of employees who attended nd what was discussed by 5129107. ; 3 4 1 Section Cited 2 3 4 5 6 7 Section Cited 1 2 3 4 5 6 7 1 2 3 4 1 2 3 4 0513012007 Cleared 5129107 STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DlVISION FACILITY EVALUATION REPORT Inland Empire CC, 3737 Main Street Suite 700 Riverside, CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL ADMINISTRATOR: MASTANEH HAZEGH ADDRESS: 9488 NINETEENTH STREET CITY: RANCHO CUCAMONGA 85 CAPACITY: TYPE OF VISIT: Case Management Massie Hazegh MET WITH: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 FACILITY NUMBER: FACILITY TYPE: TELEPHONE: STATE:CA ZIP CODE: DATE: CENSUS:43 UNANNOUNCED TIME BEGAN: TIME COMPLETED: 364809858 850 (909) 483-8250 91701 05/25/2007 07:30AM 09:00AM NARRATIVE Licensing Program Analyst (LPA) Nicole Smith visited the facility to follow up on an incident report received on 5/21/07. Upon entering classroom 107 LPA observed a Teache~s Aide (staff#1) alone with 10 children, the Teacher (staff#2) had left the classroom. Staff#1 was sitting down at a table that was toward the middle of the classroom; there were four children who were playing behind where she was sitting which Staff #1 could not visually observe. Based on these observations, the facility will be cited for Teacher Aide Qualifications and Duties for the Teache~s Aide being left alone with children and for Responsibility for Providing Care and Supervision for the children not being visually supervised. Regarding the incident report, there are no violations pertaining to Title 22 Regulations. See 8090 for deficiencies. Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility for the next 12 months. The Notice of Site Visit and Type A Deficiencies from today's visit must be posted for 30 days. Failure to keep these posted for the entire 30 days will result in an immediate $100 civil penalty for each. This report was discussed, appeal rights discussed and a copy provided. SUPERVISOR'S NAME: Tammy J. McMichael-Peirce TELEPHONE: (951)782-4970 LICENSING EVALUATOR NAME: Nicole Smith TELEPHONE: (951) 782-4952 LICENSING EVALUATOR SIGNATURE: DATE: 05/25/2007 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/25/2007 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 STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DMSION FACILITY EVALUATION REPORT (Cont) Inland Empire CC, 3737 Main Street Suite 70D Riverside, CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL DEFICIENCY INFORMATION FOR THIS PAGE: Deficiency Type POC Due Date I Section Number Type A 05/29/2007 Section Cited 101229(a)(1) Type A 05/29/2007 Section Cited 101216.2(e) FACILITY NUMBER: 364809858 VISIT DATE: 05/25/2007 DEFICIENCIES 1 2 3 4 5 6 7 Responsibility for Providing Care and Supervision: Staff#1, a Teacher's Aide, was sitting down at a table in room 107 with 10 children, 4 of the children were behind where she was sitting and were not being visually supervised PLAN OF CORRECTIONS(POCs) 1 2 3 4 5 6 7 Facility will provide an in-service training to all staff regarding Section 101229, Responsibility for Providing Care and Supervision which should include visual supervision of children at all times. Facility to submit a sign-in sheet of employees who attended and what was discussed by 5/29/07. 1 Teacher Aide Qualifications and Duties: Staff #1, a 1 Facility will provide an in-service training to all 2 Teacher's regarding Section 101216.2(e) and 2 Teacher's Aide, was left alone with 10 children 3 when Staff #2, a Teacher, left the room 3 discuss how Aides shall work under the direct 4 4 supervision of a fully qualified Teacher. Facility to 5 5 submit a sign-in sheet of employees who attended 6 6 and what was discussed by 5/29/07. 7 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 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: Tammy J. McMichael-Peirce TELEPHONE: (951)782-4970 LICENSING EVALUATOR NAME: Nicole Smith TELEPHONE: (951) 782-4952 LICENSING EVALUATOR SIGNATURE: DATE: 05/25/2007 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/25/2007 This Notice must be posted for 30 days LIC809 (FAS)· (06/04) Page: 2 of 2 STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION Inland Empire CC 3737 Main Atreet Suite 700 Riverside, Ca. CA 92501 05/14/2007 RANCHO HERITAGE SCHOOL 9235 BASELINE ROAD RANCHO CUCAMONGA, CA 91730 Letter of Deficiency Citations Cleared Dear Licensee, The following deficiencies, initially cited during a visit on 04/04/2007, have been cleared: Section Cited: 101212(d) Date Due: 04/05/2007 Plan of Correction: Corrections: Director faxed over Unusual Incident Report after follow up made by LP A. Licensee will submit written unusual incident report to CCL by 4/5/2007. LICENSING EVALUATOR NAME: Ki Ying Kim Leung Clearance Date: 05/09/2007 TELEPHONE: (951) 212-6555 LICENSING EVALUATOR SIGNATURE: 6---~c...--7 DATE: 05/14/2007 STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION Inland Empire CC 3737 Main Atreet Suite 700 Riverside, Ca, CA 92501 04/10/2007 RANCHO HERITAGE SCHOOL 9235 BASELINE ROAD RANCHO CUCAMONGA, CA 91730 Letter of Deficiency Citations Cleared Dear Licensee, The following deficiencies, initially cited during a visit on 04/04/2007, have been cleared: Section Cited: 101239(n) Plan of Correction: Date Due: 04/05/2007 Corrections: Clearance Date: Licensee will inspect all play equipment and assign staff to conduct daily inspection. Written statement and written inspection plan will be faxed to CCL at {951) 782-4985 by 415!2007, Director submitted written statement. 04/05/2007 LICENSING EVALUATOR NAME: Ki Ying Kim Leung TELEPHONE: (951) 212-6555 LICENSING EVALUATOR SIGNATURE: DATE: 04/10/2007 STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION Inland Empire CC 3737 Main Atreet Suite 700 Riverside, Ca, CA 92501 04/10/2007 RANCHO HERITAGE SCHOOL COMMENTS Please be advised of the following requirement per California Health & Safety Code: Per Section 1596.8595(b) the licensee shall post the "Letter of Deficiency Citations Cleared" verifying the licensee's compliance or noncompliance with the department's order (LIC809D or LIC 9099D) to correct a type A deficiency that is subject to posting for a period of 30 days. The "Letter of Deficiency Citations Cleared" shall be posted immediately upon receipt, immediately adjacent to, the interior side of the main door into the facility and shall be posted for a period of 30 consecutive days. Failure to comply shall result in an immediate civil penalty of one hundred dollars ($100). LICENSING EVALUATOR NAME: Ki Ying Kim Leung TELEPHONE: (951) 212-6555 LICENSING EVALUATOR SIGNATURE: DATE: 04/10/2007 Cleared POC Letter {FASJ· (06104) Page: 2 or 2 STATE OF CAUFORNlA ·HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAl SERVICES COMMUNITY CARE UCENSING DIVISION COMPLAINT INVESTIGATION REPORT Inland Empire CC, 3737 Mafn Atreet Suite 700 Riverside, Ca, CA 92501 This is an official report of an unannounced visit/investigation of a complaint received in our office on 03/30/2007 and conducted by Evaluator Ki Ying Kim Leung PUBLIC COMPLAINT CONTROL NUMBER: 09-CC-20070330101814 FACILITY NAME: RANCHO HERITAGE SCHOOL ADMINISTRATOR: CECILIA ARCE ADDRESS: 9488 NINETEENTH STREET CITY: RANCHO CUCAMONGA CAPACITY: 85 MET WITH: Massie Hazegh STATE: CENSUS: 59 UNANNOUNCED FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: 364809858 850 (909) 483-8250 91701 04/04/2007 12:00 PM 03:45PM ALLEGATION(S): 1 Physical Plant- Playground equipment fell apart. A child fell from the equipment and hit the head on the 2 ground. 3 4 5 6 7 8 9 Other- A child sustained head injury when fell off a play equipment. Facility failed to submit unusual incident report to Community Care Licensing. INVESTIGATION FINDINGS: 1 LPA Kim Leung visited the facility conducting a complaint investigation. LPA toured the facility indoor and 2 outdoor, reviewed records and interviewed staff and a child. LPA reviewed an incident report dated 3/16/2007 3 documenting child #1 fell face first on rubber chips from a climber. During visit, it was disclosed to LPA that 4 child #1 was observed climbing on a climber which was part of a Little Tike slide structure. It was disclosed the 5 climber became detached from the structure and child #1 fell face down on the cushioning material from 6 approximately 3 feet. It was disclosed that child #1 received 3 to 4 red marks on the forehead and later on it 7 turned into a small bump on forehead. LPA obtained information that child #1 was taken to the doctor the 8 same day of the incident. Community Care Licesning has not received any unusual incident report on the 9 injury up to present. Based upon the information obtained during visit. both allegations are substantiated. 10 During visit, LPA observed that the detached climber has been removed from the play structure. 11 12 LPA explained the notification requirements of AB 633 noting that upon receipt, licensee shall post and 13 Substantiated Estimated Days of Completion: SUPERVISOR'S NAME: Tammy J. McMichael-Peirce TELEPHONE: (951) 782-4970 LICENSING EVALUATOR NAME: Ki Ying Kim Leung TELEPHONE: (951) 212-6555 LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2007 I acknowledge receipt of this fonn and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2007 This report must be available at Child Care and Group Home facilities for public review for 3 years. UC9099 (FAS)- {06104) Page: 1 of 5 Control Number 09-CC-200703301 01814 STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CAUFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DMSION COMPLAINT INVESTIGATION REPORT (Cont) Inland Emplre CC, 3737 Maln Atreet Suite 700 RlvfJI"SitW, Ca, CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL FACILITY NUMBER: 364809858 VISIT DATE: 04/04/2007 NARRATIVE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. See UC809D for erred deficiencies in accordance with the California Code of Regulations Title 22, Division 12. An exit interview was conducted, appeal rights discussed and a copy of this report was provided. Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. A Fact Sheet of AB633 and LIC9224 were provided to facility during visit. SUPERVISOR'S NAME: Tammy J. McMichael-Peirce TELEPHONE: (951) 782-4970 LICENSING EVALUATOR NAME: Ki Ying Kim Leung TELEPHONE: (951) 212-6555 LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2007 I acknowledge receipt of this fonn and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2007 UC9099 (FAS). (OSI04) Page:2 of5 Control Number 09-CC-20070330101814 STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION COMPLAINT INVESTIGATION REPORT (Cont) Inland Empire CC, 3737 Main Atroet Suite 700 Riverside, Ca, CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL DEFICIENCY INFORMATION FOR THIS PAGE: Deficiency Type POC Due Date I FACILITY NUMBER: 364809858 VISIT DATE: 04/04/2007 DEFICIENCIES PLAN OF CORRECTIONS(POCs) Section Number Type A 04/05/2007 Section Cited 101239(n) 1 2 3 4 5 6 7 Fixtures, Equipment, Furniture and Supplies. The climber became detached from the Little tike play structure while a child was climbing on it. The child fell face down on the cushioning material from the play equipment. 1 2 3 1 2 3 4 5 6 7 Licensee will inspect all play equipment and assign staff to conduct daily inspection. Written statement and written inspection plan will be faxed to CCL at (951) 782-4985 by 4/5/2007. 1 2 3 4 5 6 7 4 5 6 7 1 2 3 4 5 6 7 4 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 5 6 7 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: Tammy J. McMichael-Peirce TELEPHONE: (951) 782-4970 LICENSING EVALUATOR NAME: Ki Ying Kim Leung TELEPHONE: (951) 212-6555 LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2007 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: ~)\~ DATE: 04/04/2007 This Notice must be posted for 30 days LIC9099 (FAS) • (06/04) Page: 3 of 5 STATE OF CALIFORNIA· HEALTil AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FACILITY EVAlUATION REPORT Inland Empiro CC, 3737 Main Atreet Suite 700 Riverside, Ca, CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL ADMINISTRATOR: CECILIA ARCE ADDRESS: 9488 NINETEENTH STREET CITY: RANCHO CUCAMONGA CAPACITY: 85 TYPE OF VISIT: Case Management MET WITH: Massie Hazegh 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 STATE:CA CENSUS: 59 UNANNOUNCED FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 364809858 850 (909) 483-8250 91701 04/04/2007 12:00 PM 03:45PM NARRATIVE LPA Kim Leung visited the facility conducting a complaint investigation. LPA took census and observed one teacher and one aide with no Early Childhood Education (ECE) units supervising 23 children in Room 108. Among the 23 children, some were laying down napping but some were still up having aclivity and there was a child in the bathroom. See UC809D for deficiency cited per California Code of Regulations title 22, Division 12. An exit interview was conducted, appeal rights discussed and a copy of this report was provided. Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. A Fact Sheet of AB633 and LIC9224 were provided to facility during visit. 16 17 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME: Tammy J. McMichael-Peirce TELEPHONE: (951) 782-4970 LICENSING EVALUATOR NAME: Ki Ying Kim Leung TELEPHONE: (951) 212-6555 LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2007 I acknowledge receipt of this fonn and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: ~~ DATE: 04/04/2007 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC809 {FAS) • {OGI04) Page: 1 of2 CALIFORNIA DEPARTMENT OF SOCIAL SERViCES STATE OF CALIFORNIA· HEALTii AND HUMAN SERVICES AGENCY COMMUNITY CARE UCENS!NG DMSION FACiliTY EVALUATION REPORT (Cont) Inland Empire CC, 3737 Main Atrnet Suite 700 Riverside, Ca, CA. 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL DEFICIENCY INFORMATION FOR THIS PAGE: Deficiency Type POC Due Date I FACILITY NUMBER: 364809858 VISIT DATE: 04/04/2007 DEFICIENCIES PLAN OF CORRECTIONS(POCs) Section Number Type A 04/05/2007 Section Cited 101216.3(b) 1 Teacehr-Child Ratio. LPA observed one teacher 2 and one aide with no Early Childhood Education 3 (ECE) units supervising 23 children in Room 108. 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 Licensee will ensure that proper teach-child ratio be maintained at all times. Licensee will submit staffing plan for each room to CCL by 4/512007. The plan will include contingency plan detailing how facmty is going to maintain proper ratio when regular teaching staff are absent without advance notice. 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: Tammy J. McMichael-Peirce TELEPHONE: (951) 782-4970 LICENSING EVALUATOR NAME: Ki Ying Kim Leung TELEPHONE: (951) 212-6555 LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2007 I acknowledge receipt of this fonn and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: hJ/h DATE: 04/04/2007 This Notice must be posted for 30 days UCB09 (FAS) • (06104) Page:2of2 Control Number 09-CC-200703301 01814 STATE OF CALIFORNIA. HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVJSIDN COMPLAINT INVESTIGATION REPORT (Cont) Inland Empire CC, 3737 Main Atroot Suite 700 Rlvemid&, Ca. CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL DEFICIENCY INFORMATION FOR THIS PAGE: Deficiency Type POC Due Date I Section Number TypeS 04/05/2007 Section Cited 101212(d) FACILITY NUMBER: 364809858 VISIT DATE: 04104/2007 DEFICIENCIES PLAN OF CORRECTIONS(POCs) 1 Reporting Requirements. A child fell face down 2 from a climber. The child received several red 3 marks and a bump on forehead. The child was 4 taken to the doctor by parent. Facility failed to 5 submit unusual incident report to Community Care 6 Licensing. 1 licensee will submit written unusual incident report 2 to CCL by 4/5/2007. 3 4 7 5 6 7 1 2 1 2 3 4 3 5 5 6 4 6 7 7 1 2 1 2 3 3 4 4 5 6 7 5 6 1 1 2 7 2 3 3 4 4 5 6 7 5 6 7 Failure to correct the cited deficlency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment SUPERVISOR'S NAME: Tammy J. McMichael-Peirce TELEPHONE: (951) 782-4970 LICENSING EVALUATOR NAME: Ki Ying Kim Leung TELEPHONE: (951) 212-6555 LICENSING EVALUATOR SIGNATURE: DATE: 0410412007 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: ~\"'ilA UC9099 (FAS)- (06104) DATE: 0410412007 Page:4 ofS STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION Inland Empire CC 3737 Main Atreet Suite 700 Riverside, Ca, CA 92501 10/20/2006 RANCHO HERITAGE SCHOOL 9235 BASELINE ROAD RANCHO CUCAMONGA, CA 91730 Letter of Deficiency Citations Cleared Dear Licensee, The following deficiencies, initially cited during a visit on 10/17/2006, have been cleared: Section Cited: 101161(a) Plan of Correction: Date Due: 10/20/2006 Corrections: Current director stated that staff had ceased pulling school.age children in any of the licensed activity areas since she had been designated as the director. Director will issue a memo to an staff as a reminder. Copy of the memo will be faxed at (951) 782-4985 by 10/20/06. Director faxed copy of memo. LICENSING EVALUATOR NAME: Ki Ying Kim Leung Clearance Date: 10/18/2006 TELEPHONE: (951) 782-4200 LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2006 STATE OF CALIFORNIA. HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION Inland Empire CC 3737 Main Atreet Suite 700 Riverside, Ca, CA 92501 10/20/2006 RANCHO HERITAGE SCHOOL COMMENTS Please be advised of the following requirement per California Health & Safety Code: Per Section 1596.8595(b) the licensee shall post the "Letter of Deficiency Citations Cleared" verifying the licensee's compliance or noncompliance with the department's order (LIC809D or LIC 9099D) to correct a type A deficiency that is subject to posting for a period of 30 days. The "Letter of Deficiency Citations Cleared" shall be posted immediately upon receipt, immediately adjacent to, the interior side of the main door into the facility and shall be posted for a period of 30 consecutive days. Failure to comply shall result in an immediate civil penalty of one hundred dollars ($1 00). LICENSING EVALUATOR NAME: Ki Ying Kim Leung TELEPHONE: (951) 782-4200 LICENSING EVALUATOR SIGNATURE: DATE: 10/2012006 Cleared POC Letter (FAS) • (06104) Page: 2 of 2 STATE OF CALIFORNIA ~HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING OMSION COMPLAINT INVESTIGATION REPORT Inland Empire CC, 3737 Main Atreot Suite 700 Riverside, Ca, CA 92501 This is an official report of an unannounced visit/investigation of a complaint received in our office on 09/26/2006 and conducted by Evaluator Ki Ying Kim Leung PUBLIC COMPLAINT CONTROL NUMBER: 09-CC-20060926151227 FACILITY NAME: RANCHO HERITAGE SCHOOL ADMINISTRATOR: CECILIA ARCE ADDRESS: 9488 NINETEENTH STREET CITY: RANCHO CUCAMONGA CAPACITY: 85 STATE: CENSUS:2 UNANNOUNCED MET WITH: Massie Hazegh FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME VISIT BEGAN: TIME COMPLETED: 364809858 850 (909) 483-8250 91701 10/17/2006 05:45PM 07:00PM ALLEGATION(S): 1 License- Facility had school age children present. 2 3 4 5 6 7 8 9 INVESTIGATION FINDINGS: 1 LPA Kim Leung visited the facility to continue investigating the complaint. LPA observed no school-age 2 children in any of the preschool activity rooms during visit. LPA observed 2 school-age children at the front 3 office waiting to be picked up by parents. LPA was told that they were brought from private school upstairs by 4 staff at the end of the day to wait for their parents to pick them up. LPA conducted interviews with staff and 5 children. Other interviews were conducted during previous visit. LPA discussed the allegation with director Ms. 6 Massie Hazegh. Ms. Hazegh told LPA that she was aware of that staff had put school-age children in one of 7 the preschool rooms in the past on several occasions but they were not commingled with any preschool 8 children. Ms. Hazegh stated that she understood that it was a violation so since she had been designated as 9 the facility director, she had trained all of her staff that school-age children should not be using any of the 10 activity areas licensed for preschool. Based upon the infonnation obtained, this complaint is substantiated. 11 12 Exit interview was conducted with Ms. Hazegh and appeal rights were explained. 13 Substantiated Estimated Days of Completion: SUPERVISOR'S NAME: Tammy J. McMichael-Peirce TELEPHONE: (951) 782-4970 LICENSING EVALUATOR NAME: Ki Ying Kim Leung TELEPHONE: (951) 782-4200 LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2006 I acknowledge receipt of this fonn and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/1712006 This report must be available at Child Care and Group Home facilities for public review for 3 years. UC9099 (FAS) ~ (OG/04} PaQG: 1 of 2 Control Number 09-CC-20060926151227 STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION COMPLAINT INVESTIGATION REPORT (Cont) Inland Empire CC, 3737 Main Au-t SUIW 700 Rlvwside, Ca, CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL DEFICIENCY INFORMATION FOR THIS PAGE: Deficiency Type POC Due Date I FACILITY NUMBER: 364809858 VISIT DATE: 10/17/2006 DEFICIENCIES PLAN OF CORRECTIONS(POCs) Section Number TypeB 10/20/2006 Section Cited 101161(a) 1 2 3 4 5 6 7 Limitations on Capacity and Ambulatory Status. The facility had school-age children in one of the activity rooms licensed for this preschool program in the past. 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 Current director stated that staff had ceased putting school-age children in any of the licensed activity areas since she had been designated as the director. Director will issue a memo to all staff as a reminder. Copy of the memo will be faxed at (951) 782-4985 by 10/20/06. 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: Tammy J. McMichael-Peirce TELEPHONE: (951) 782-4970 LICENSING EVALUATOR NAME: Ki Ying Kim Leung TELEPHONE: (951) 782-4200 LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2006 I acknowledge receipt of this fonn and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: ~-+j;(;//1 UC9099(FAS)- (GS/04) DATE: 10/17/2006 Page:2 of2 STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION Inland Empire CC 3737 Main Atreet Suite 700 Riverside, Ca, CA 92501 10/05/2006 RANCHO HERITAGE SCHOOL 9235 BASELINE ROAD RANCHO CUCAMONGA, CA 91730 Letter of Deficiency Citations Cleared Dear Licensee, The following deficiencies, initially cited during a visit on 09/01/2006, have been cleared: Section Cited: 101229(a) Plan of Correction: LPA told a teacher who walked passed the hallway and the teacher brought the child back to the nap room. Licensee will ensure visual supervision be provided to all children at all time. In-service training wlll be provided to staff. Content of training with staffs signatures will be faxed to CCL by 9/5/06, the next business day. Date Due: 09/05/2006 Corrections: Licensee faxed proof of training with staff's signatures. Section Cited: 101238(a) Date Due: 09/05/2006 Plan of Correction: Corrections: Licensee faxed pictures and written statement. Photos were received on Licensee will cover the piping. Pictures and written statement will be submitted to CCL by 9/5/06, the next business day. Clearance Date: 09/05/2006 Clearance Date: 09/05/2006 9/12/06. LICENSING EVALUATOR NAME: Ki Ying Kim Leung TELEPHONE: (951) 782-4200 LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2006 CALIFORNIA DEPARTMENT OF SOCIAl SERVICES COMMUNITY CARE LICENSING DIVISION STATE OF CALIFORNIA • HEALTH AND HUMAN SERVICES AGENCY Inland Empire CC 3737 Main Atreet Suite 700 Riverside, Ca, CA 92501 10/05/2006 RANCHO HERITAGE SCHOOL COMMENTS Please be advised of the following requirement per California Health & Safety Code: Per Section 1596.8595(b) the licensee shall post the "Letter of Deficiency Citations Cleared" verifying the licensee's compliance or noncompliance with the department's order (LIC809D or LIC 9099D) to correct a type A deficiency that is subject to posting for a period of 30 days. The "Letter of Deficiency Citations Cleared" shall be posted immediately upon receipt, immediately adjacent to, the interior side of the main door into the facility and shall be posted for a period of 30 consecutive days. Failure to comply shall result in an immediate civil penalty of one hundred dollars ($1 00). LICENSING EVALUATOR NAME: Ki Ying Kim Leung TELEPHONE: (951) 782-4200 LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2006 Cleared POC Letter (FAS} • {06/04) Page: 2 of 2 STATE OF CAUFORNIA- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION Inland Empire CC 3737 Main Atreet Suite 700 Riverside, Ca. CA 92501 09/08/2006 RANCHO HERITAGE SCHOOL 9235 BASELINE ROAD RANCHO CUCAMONGA, CA 91730 Letter of Deficiency Citations Cleared Dear Licensee, The following deficiencies. initially cited during a visit on 09/01/2006, have been cleared: Section Cited: 101238(a) Plan of Correction: Licensee has appointment with pest control to spray the facility on 9/2106. Janilorwifl clean up the facility after the spray work before the program resumes on 9/5/06, the day after the Labor Day weekend. Copy of the pest control invoice and written statement will be faxed to CCL at (951) 782-4985 by 9/5/06, LICENSING EVALUATOR NAME: Ki Ying Kim Leung Date Due: 09/05/2006 Corrections: Clearance Date: Licensee sent copy of pest control 09/05/2006 invoice and payment check for the service. Per voice, the work was done on 9/3/06. TELEPHONE: (951) 782-4200 LICENSING EVALUATOR SIGNATURE: DATE: 0910812006 STATE OF CAUFORNIA • HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION Inland Empire CC 3737 Main Atreet Suite 700 Riverside, Ca, CA 92501 09/08/2006 RANCHO HERITAGE SCHOOL COMMENTS Please be advised of the following requirement per California Health & Safety Code: Per Section 1596.8595(b} the licensee shall post the "Letter of Deficiency Citations Cleared" verifying the licensee's compliance or noncompliance with the department's order (LIC809D or LIC 90990) to correct a type A deficiency that is subject to posting for a period of 30 days. The "Letter of Deficiency Citations Cleared" shall be posted immediately upon receipt, immediately adjacent to, the interior side of the main door into the facility and shall be posted for a period of 30 consecutive days. Failure to comply shall result in an immediate civil penalty of one hundred dollars ($1 00). LICENSING EVALUATOR NAME: Ki Ying Kim Leung TELEPHONE: (951) 782-4200 LICENSING EVALUATOR SIGNATURE: / DATE: 09/15/2006 Cleared POC Letter (FAS) • (06/04) Page: 2 of 2 SEP. -OJ' 06(FR!l COXFIRMATION REPORT TR.\~S;"I.ll SS ION .TRANSACTIONlSl ='-·o. RIVERSIDE TEL:9C '82 p. -l985 '-* COMPLETED DATE/TIME -2.8 SEP. C 15:58 1 15:56 DESTINATION DURATION PGS STATUS MODE 19094987572 0" 01' 32H 005 OK N ECM &TATE OF CALIFORNIA -HI'AI.'I'IlAiiD HUIIAN lli!RIIIcell AGENCY c.t.LIFORHIA D~PARTIIU!NT OF eoew. 8!1t111Cl08 COMNUHITVCARE I.JCEN8ING DM6ION FACIUTY EVALUATION REPORT Inland Emph cc, m711a!n Amlt SURa 700 RJvanlldl, ca, CA 1uo1 FACIUTY NUMBER: FACIUTY TYPE: TELEPHONE: ZIP CODE: FACILITY NAMI!: RANCHO HERITAGE SCHOOL ADMINISTRATOR: CECILIA ARCE ADDRESS: 9488 NINETEENTH STREET CITY: RANCHO CUCAMONGA CAPACITY: 85 TYPE OF VISIT: Case Management- Other MET WITH: Mastaneh Haz.egh STATE:CA DATE: CENSUS:45 UNANNOUNCED TIME BEGAN: TIME COMPLETED: 364809858 850 (909) 483--8250 91701 09101/2006 11:30AM 02:30PM NARRATIVE 1 2 3 4 5 6 7 B 9 10 11 LPA Kim Leung vis~ed the facility conducting a complaint investigation. During visit, LPA observed a :;.year old child walking from the hallway to the cubbies in one of the 3-year old activity rooms unattended. LPA osberved no teaching staff in the hallway supervising the child. On the playground, LPA observed exposed piping on the ground in the areas where the two slide structures are located. Refer to LIC809D for deficiencies cited per California Code of RegulaHons TIHe 22, Division 12Exit interview was conducted with Ms. Massie Hazegh and appeal rights were explained. 12 13 14 15 16 17 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME: Tammy J. McMicnael-Peirce TELEPHONE: (951) 782-4970 (i!j l STATE OF CALIFORNIA • HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FACILITY EVALUATION REPORT Inland Empire CC, 3737 Main Atreet Sui!e 700 Riverside, Ca, CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL ADMINISTRATOR: CECILIA ARCE ADDRESS: 9488 NINETEENTH STREET CITY: RANCHO CUCAMONGA 85 CAPACITY: TYPE OF VISIT: Case Management Mastaneh Hazegh MET WITH: 1 2 3 4 5 FACILITY NUMBER: FACILITY TYPE: TELEPHONE: STATE:CA ZIP CODE: CENSUS: 45 DATE: UNANNOUNCED TIME BEGAN: TIME COMPLETED: 364809858 850 (909) 483-8250 91701 09/01/2006 11:30 AM 02:30PM NARRATIVE LPA Kim Leung visited the facility conducting a complaint investigation. During visit, LPA observed a 3-year old child walking from the hallway to the cubbies in one of the 3-year old activity rooms unattended. LPA osberved no teaching staff in the hallway supervising the child. On the playground, LPA observed exposed piping on the ground in the areas where the two slide structures are located. Refer to LIC809D for deficiencies cited per California Code of Regulations Title 22, Qivision 12. 6 7 8 Exit interview was conducted with Ms. Massie Hazegh and appeal rights were explained. 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME: Tammy J. McMichael-Peirce TELEPHONE: (951) 782-4970 LICENSING EVALUATOR NAME: Ki Ying Kim Leung TELEPHONE: (951) 782-4200 LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2006 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2006 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC809 (FAS) • (06/04) Page: 1 of2 STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FACILITY EVALUATION REPORT (Cont) Inland Empire CC, 3737 Main Atreet Suite 700 Riverside, Ca, CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL DEFICIENCY INFORMATION FOR THIS PAGE: Deficiency Type POC Due Date I Section Number Type A 09/05/2006 Section Cited 101229(a) Type A 09/05/2006 Section Cited 101238(a) FACILITY NUMBER: 364809858 VISIT DATE: 09/01/2006 DEFICIENCIES 1 2 3 4 5 6 Responsibility for Providing Care and Supervision. LPA observed a 3-year old child walking from the hallway to the cubbies in one of the 3-year old activity rooms without supervision. PLAN OF CORRECTIONS(POCs) 1 2 3 4 5 6 7 LPA told a teacher who walked passed the hallway and the teacher brought the child back to the nap room. Licensee will ensure visual supervision be provided to all children at all time. ln·service training will be provided to staff. Content of training with staffs signatures will be faxed to CCL by 7 915106, the next business day. 1 Building and Grounds. LPA observed exposed 2 piping on playground. That presents tripping 3 hazard. 4 5 6 1 Licensee will cover the piping. Pictures and written 2 statement will be submitted to CCL by 9/5/06, the 3 next business day. 4 5 6 7 7 1 2 3 4 5 6 1 2 3 4 5 6 7 7 1 2 3 4 5 6 1 2 3 4 5 6 7 7 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: Tammy J. McMichael-Peirce TELEPHONE: (951) 782-4970 LICENSING EVALUATOR NAME: Ki Ying Kim Leung TELEPHONE: (951) 782-4200 LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2006 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: 1;-yyt; DATE: 09/01/2006 This Notice must be posted for 30 days UC809 (FAS) • (06/04) Page: 2of2 STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAl. SERVICES COMMUNITY CARE LICENSING DIVISION COMPLAINT INVESTIGATION REPORT Inland Empire CC, 3737 Main Atreet Suite 700 Riverside, Ca, CA 92501 This is an official report of an unannounced visiUinvestigation of a complaint received in our office on 08/30/2006 and conducted by Evaluator Ki Ying Kim Leung PUBLIC COMPLAINT CONTROL NUMBER: 09-CC-20060830095617 FACILITY NAME: RANCHO HERITAGE SCHOOL ADMINISTRATOR: CECILIA ARCE ADDRESS: 9488 NINETEENTH STREET RANCHO CUCAMONGA CITY: CAPACITY: 85 MET WITH: Mastaneh Hazegh FACILITY NUMBER: FACILITY TYPE: TELEPHONE: STATE: ZIP CODE: CENSUS: 45 DATE: UNANNOUNCED TIME VISIT BEGAN: TIME COMPLETED: 364809858 850 (909) 483-8250 91701 09/01/2006 11:30AM 03:30PM ALLEGATION(S): 1 Physical Plant- On or about 08/30/06, cockroaches were observed in the two year old room. 2 3 4 5 6 7 8 9 INVESTIGATION FINDINGS: 1 LPA Kim Leung visited the facility conducting a complaint investigation. LPA met with Ms. Vivi Valentina and 2 Ms. Mastaneh (Massie) Hazegh. LPA toured the facility indoor and outdoor and interviewed staff during visit. 3 In the activity room for 2-year old children, LPA observed a cockroach in the floor drain near the food serving 4 counter. It was also observed by Ms. Valentina, Ms. Hazegh and the two teachers in the room. During 5 interviews, LPA obtained information that 2 days ago on 8/30/06, there was a cockroach under the children's 6 handwashing sink in the 2-year old room, and a week ago, there was cockroach crawling under the sink in 7 children's bathroom inside the 2-year old. During visit, LPA obtained information that cockroaches had been 8 seen in other activity rooms as well several weeks ago. Based upon the observation and information obtained 9 during visit, this complaint is substantiated. 10 11 Exit interview was conducted with Ms. Massie Hazegh and appeal rights were explained. 12 13 Estimated Days of Completion: Substantiated SUPERVISOR'S NAME: Tammy J. McMichael-Peirce TELEPHONE: (951) 782-4970 LICENSING EVALUATOR NAME: Ki Ying Kim Leung TELEPHONE: (951) 782-4200 LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2006 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: ~;vL DATE: 09/01/2006 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS) • (06/04) Page: 1 or 2 Control Number 09-CC-20060830095617 STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION COMPLAINT INVESTIGATION REPORT (Cont) Inland Empire CC, 3737 Main Atreet Sulle 700 Riverside, Ca, CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL DEFICIENCY INFORMATION FOR THIS PAGE: FACILITY NUMBER: 364809858 VISIT DATE: 09/01/2006 Deficiency Type POC Due Date I Section Number Type A 09/05/2006 Section Cited 101238(a) DEFICIENCIES 1 Building and Grounds. The facility had 2 cockroaches in activity rooms and children's 3 bathroom. PLAN OF CORRECTIONS(POCs) 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 4 Licensee has appointment with pest control to spray the facility on 9/2/06. Janitor will clean up the facility after the spray work before the program resumes on 9/5/06, the day after the Labor Day weekend. Copy of the pest control invoice and written statement will be faxed to CCL at (951) 782-4985 by 9/5/06. 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: Tammy J. McMichael-Peirce TELEPHONE: (951) 782-4970 LICENSING EVALUATOR NAME: Ki Ying Kim Leung TELEPHONE: (951) 782-4200 LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2006 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2006 This Notice must be posted for 30 days UC9099 (FAS) • (OG/04) Page: 2 of 2 STATE OF CALIFORNIA. HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSlNG DMSlON Inland Emplro CC, 3737 Main Street Sulte700 Rlvefll.l®, Ca, CA 92501 FACILITY EVALUATION REPORT (Cont) FACILITY NAME: RANCHO HERITAGE SCHOOL DEFICIENCY INFORMATION FOR THIS PAGE: Deficiency Type POC Due Date/ Section Number Type A 05/20/2004 Section Cited 101230 VISIT DATE: 05/20/2004 DEFICIENCIES PLAN OF CORRECTIONS(POCs) 1 2 3 4 5 6 7 Activities/Napping: Observed 1 teacher supervising 18 children during nap time. 11 of the children were awake. One teacher can supervise 24 napping children. As the children start waking up, the regular teacher-child ratio applies which is one to twelve. Since that was the third citation within a 12-month period for the same deficiency, an immediate civil 1 2 3 4 5 6 TypeS 1 2 penalty of 150.00 will be assessed on this date and 150.00 each day until the correction is made. Section Cited 3 1 2 3 4 5 6 7 4 5 6 7 1 2 ~ Ac.co!ZD!tl6 1Tt3Nl 4 To MRs.IHomAS ~ THe FIR:.T PAGe.. We,. I+Ai> AN oTlt6.R. IE.A c..HER 7 1 6 7 />..T ~: 0t> (\) M 1 2 3 4 wef<.e. \..\f G\\-1 1.-DRBN <;;.TAR.I\NG To wA ~C-t. fRo IV\. N A r · 5 in·service training class with all staff reviewing title 22 regulations regarding napping and teacher~ child ratios. A copy of training outline signed by all staff members shall be submitted by 08/08/03. 2 l-0\-\\C..\\ <_}I.A<:.l STf-.P O~TSIJ)e ~ t1F- Cl-PrSS RooM· ANT:> 5 6 5 The center must stay within proper teacher-child ratio at all times. During nap time, if children are awake, the center need to have the appropriate number of staff supervising the children. Licensing shall conduct an 7 1 2 3 4 5 6 6 7 7 Failure to correct the cited deliciency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment SUPERVISOR'S NAME: Gary Andary TELEPHONE: (909) 782-4970 LICENSING EVALUATOR NAME: Kimberlytl/bmas~~ \ TELEPHONE: (909) 782-4202 LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2004 4l! tv--~b J \'VL·V I acknowledge receipt of this fonn and unders ined and received. FACILITY REPRESENTATIVE SIGNATURE::_s~~==-:Z:t:~~~~~DATE: 05/20/2004 LIC809 {FAS) • (4100) Page: 2 of 1 STATE OF CAUFORNIA- HEALnt AND HUMAN SERVICES AGENCY CAUFORNtA DEPARTMENT OF SOCIAL SERV1CES COMMUNITY CARE UCENSING DMSKlN Inland Empire CC, 3737 Main StrMt Suite 700 Riverside, Ca, CA 92501 CIVIL PENALTY ASSESSMENT FACIUTY NAME DATE RANCHO HERITAGE SCHOOL FACIU1Y ADDRESS 05/20/2004 CIIT 9488 NINETEENTH STREET STATE RANCHO CUCAMONGA ZlPCODE CA 91701 UCENSEE(S}IOPERATOR FACJUTY NUMBER RANCHO HERITAGE SCHOOL 364809858 LICENSED FACILITY Civil penalties can be assessed against any facility which fails to take corrective action within prescribed time periods, per California Health and Safety Code Sections 1548, 1568.0822, 1569.99. You are hereby notified that a ivil penalty has been assessed. rrhe above facility has been found in violation of the California Code of Regulations, Title 22, Divisions 6, and/or 12, Section(s} and/or California Health and Safety Code, Chapters 3, 3.01, 3.2, 3.4, and 3.5 Section(s} A Facility Evaluation Report (LIC 809} was issued on violation(s} would result in a civil penalty. 0 07/30/2003 giving notice that failure to correct the above Because you failed to make the corrections specified on the LIC 809, a civil penalty of $0.00 is assessed for the period from through . 0 A civil penalty of $50 per violation per day, up to a maximum of $150 per day will be assessed. This will continue until correction(s} are made to comply with the licensing laws, regulations, and approval of the California Department of Social Services or authorized licensing agency. [gJ Because you repeated a violation of the same subsection within a 12 month period, an immediate civil penalty of $150.00 is assessed for 05/20/2004, the day the deficiency was cited. [gJ All Facility Types: Second citation within a 12 month period; an immediate civil penalty of $150 per violation then $50 per day per violation until corrections are made. 0 0 Residential Care Facility for the Elderly (RCFE}, Residential Care Facility for the Chronically ILL (RCF-CI}: Third citation within 12 month period; an immediate civil penalty of $1,000 per violation then $100 per day per violation until corrections are made. 0 Family Child Care Homes (FCCH}, Child Care Centers (CCC}, Community Care Facility (CCF}: Third citation within 12 month period; an immediate civil penalty of $150 per violation then $150 per day per violation until corrections are made. Violations which result in injury, sickness, or death: An immediate civil penalty of $150 per violation and then $150 per day per violation until corrections are made. YOU WILL RECEIVE A BILL IN THE MAIL DO NOT SEND MONEY UNTIL YOU RECEIVE YOUR BILL! Gary Andary, Local UnH Manager LIC421 (FAS). (10/02) Page: 1 of2 STATE OF CAUFORNIA~ HEALTH AND HUMAN SERVICES AGENCY CAUFORNtA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSfNG DNistON fnland Empire CC, 3737 Main Street SUI to 700 R1Vf!I'Side, Ca, CA 92501 FACILITY EVALUATION REPORT FACILITY NAME: DIRECTOR: ADDRESS: CITY: RANCHO HERITAGE SCHOOL FACILITY NUMBER: CECILIAARCE 9488 NINETEENTH STREET RANCHO CUCAMONGA FACILITY TYPE: TELEPHONE: ZIP CODE: STATE:CA 60 CAPACITY: TYPE OF VISIT: Case Management HaiHazegh MET WITH: CENSUS:46 UNANNOUNCED DEFICIENCY INFORMATION FOR THIS PAGE: DATE: TIME BEGAN: TIME COMPLETED: 364809858 850 (909) 483-8250 91701 05/20/2004 02:00PM 04:15PM CIVIL PENALTY INFORMATION: COMMENTS/DEFICIENCIES 1 2 3 4 LPA Kim Thomas arrived at the facility to conduct a case management visit per the non compliance conference dated 10/01/03. LPA toured the facility, inside and out and records were reviewed. The following were observed: 5 6 7 8 1.The playground was observed to have adequate cushioning material. 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 2. LPA did not observe any fungus, mushrooms or any broken pieces of wood on the playground. The playground was observed to be in substantial compliance on this date. 3. Electrical outlets were covered. 4. During nap time, one staff member was supervising 18 children. 11 of the children were awake. The Licensee states that the second teacher had went to another classroom leaving the center out of ratio. Please see Lie 809d for deficiencies cited on todays visit. Exit interview held and appeal rights were discussed. 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: Gary Andary LICENSING EVALUATOR NAME: TELEPHONE: (909) 782-4970 Kimbert~T mas LICENSING EVALUATOR SIGNATURE:; v \ 'M. I acknowledge receipt of this form and understa FACILITY REPRESENTATIVE SIGNATURE: LICB09 (FAS} ~ (4196) ni "df1 L/Vl1 ll~ TELEPHONE: (909) 782-4202 DATE: 05/20/2004 hts as explained and received. DATE: 05/20/2004 Page: 1 of 1 STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSING OMS/ON Inland Empim CC, 3737 Main Strel.lt Sulto 700 Riverside, Ca, CA 92501 CIVIL PENALTY ASSESSMENT DATE FACIUTY NAME RANCHO HERITAGE SCHOOL FACIUTY ADDRESS 05/20/2004 CITY 9488 NINETEENTH STREET STATE RANCHO CUCAMONGA ZIP CODE CA 91701 LICENSEE(S)IOPERATOR FACIUTY NUMBER RANCHO HERITAGE SCHOOL 364809858 LICENSED FACILITY Civil penalties can be assessed against any facility which fails to take corrective action within prescribed time periods, per California Health and Safety Code Sections 1548, 1568.0822, 1569.99. You are hereby notified that a ivil penalty has been assessed. f...he above facility has been found in violation of the California Code of Regulations, Title 22, Divisions 6, and/or 12, Section(s) and/or California Health and Safety Code, Chapters 3, 3.01, 3.2, 3.4, and 3.5 Section(s) A Facility Evaluation Report (LIC 809) was issued on violation(s) would result in a civil penalty. D 07/30/2003 giving notice that failure to correct the above Because you failed to make the corrections specified on the LIC 809, a civil penalty of $0.00 is assessed for the period from through . 0 A civil penalty of $50 per violation per day, up to a maximum of $150 per day will be assessed. This will continue until correction(s) are made to comply with the licensing laws, regulations, and approval of the California Department of Social Services or authorized licensing agency. IZ] Because you repeated a violation of the same subsection within a 12 month period, an immediate civil penalty of $150.00 is assessed for 05/20/2004, the day the deficiency was cited. 0 iZJ All Facility Types: Second citation within a 12 month period; an immediate civil penalty of $150 per violation then $50 per day per violation until corrections are made. D Residential Care Facility for the Elderty (RCFE), Residential Care Facility for the Chronically ILL (RCF-CI): Third citation within 12 month period; an immediate civil penalty of $1,000 per violation then $100 per day per violation until corrections are made. 0 Family Child Care Homes (FCCH), Child Care Centers (CCC), Community Care Facility (CCF): Third citation within 12 month period; an immediate civil penalty of $150 per violation then $150 per day per violation until corrections are made. Violations which result in injury, sickness, or death: An immediate civil penalty of $150 per violation and then $150 per day per violation until corrections are made. YOU WILL RECEIVE A BILL IN THE MAIL. DO NOT SEND MONEY UNTIL YOU RECEIVE YOUR BILL! NAME OF LICENSING PROGRAM ANALYST NAME OF FACILITY REPRESENTATIVEITITLE Kimberly Thomas NSING PROGRA ANALYST Ll 1<'VL SUPERVI \(\ bYk /SIGNATURE (FOR INTERNAL USE ONLY} Gary Andary, Local Unit Manager LIC421 (FAS) ~ (10/02) ATE 5/z.o/o4 Page: 1 of2 .fE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AG CALIFORNIA DEPARTMENT OF SOCIAL SERVICES NOTICE OF CIVIL PENALTIES DUE li2J D Initial Invoice INVOICE NO. _2~~0924_ _ Final Notice DISTRICT OR COUNTY OFFICE NUMBER 0 9 · - - I FACILITY NAME Rancho Heritage School FISCAL YEAR I FACILITY AOORE.SS 2003/2004 FACILITY TYPE 9488 Nineteenth Street DCC CITY STATE DATE LIC 422 SENT 7-09-2004 PENALTY PCA CODE 84850 ZIP CODE! : Rancho Cucamonga, CA 91701 FACILITY NUMBER ! 364809858 UCENSEE(S) OR UNLICENSED FACILITY OPERATOR Rancho Heritage School ADDRESS 9235 Baseline Road STATE CITY ZIP CODE Rancho Cucamonga, CA 91730 icensing Program Supervisor The California Health and Safety Code, Sections 1548, 1568.0822, 1569.49, 1596.99, and 1597.62 provides for the imposition of civil penalties against any facility which fails to take corrective action within prescribed time periods. The California Health and Safety Code, Sections 1547, 1568.0821, 1569.485, 1596.89, 1596.891 and 1597.61 provides for the imposition of civil penalties against any unlicensed facility which fails to take corrective action within prescribed time periods. The California Health and Safety Code, Sections 1522, 1568.09, 1569.17, 1596.871, and 1596.8712 provides for the irr>position of immN Inland Empire CC, 3737 Main Stre&t Suite 700 Rlvern!de, CA 92501 FACILITY EVALUATION REPORT FACILITY NAME: DIRECTOR: ADDRESS: CITY: RANCHO HERITAGE SCHOOL FACILITY NUMBER: CECILIA ARCE 9488 NINETEENTH STREET RANCHO CUCAMONGA FACILITY TYPE: TELEPHONE: ZIP CODE: STATE:CA 79 CAPACITY: TYPE OF VISIT: Case Management CeciliaArce MET WITH: 364809858 850 (909) 483-8250 CENSUS:40 DATE: UNANNOUNCED TIME BEGAN: TIME COMPLETED: DEFICIENCY INFORMATION FOR THIS PAGE: 91701 09/29/2004 02:25PM 04:08PM CIVIL PENALTY INFORMATION: COMMENTS/DEFICIENCIES 1 2 LPA Kim Thomas arrived at the facility t conduct a case management visit per the noncompliance conference meeting held on 04/23/02. The following items were reviewed: 3 4 5 6 1. LPA observed exposed piping in the fall zone of the climbing equipment. 2. LPA observed 2 infants mixed with the 2 year old preschool children 7 8 Please see Lie 809d for deficiencies erred on todays visit. 9 10 Exit interview and appeal rights were discussed with Cecilia Arce 11 12 13 14 15 16 17 18 19 20 21 22 23 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: Marianne Donley TELEPHONE: (951) 782-4200 LICENSING EVALUATOR NAME: Kimbe ly T TELEPHONE: (951) 782-4202 LICENSING EVALUATOR SIGNATU DATE: 09/29/2004 I acknowledge receipt of this form and unders~j~no;l !i"'i liceJIS)ng appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: UC8fJ9: {FAS) ~ (06104) U"vt-....- I~L DATE: 09/29/2004 Page: 1 of1 STATE OF CALIFORNIA~ HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCW. SERVICES COMMUNITY CARE LICENSING DMSK>N Inland Empire CC, 3737 Mafn Stroet Suite 700 CIVIL PENALTY ASSESSMENT Riverside, CA 92501 DATE FACILITY NAME RANCHO HERITAGE SCHOOL 09/29/2004 CITY FACIUTY ADDRESS 9488 NINETEENTH STREET RANCHO CUCAMONGA ZIP CODE STATE CA 91701 FACiliTY NUMBER LICENSEE(S)IOPERATOR RANCHO HERITAGE SCHOOL 364809858 LICENSED FACILITY ~ivil penalties can be assessed against any facility which fails to take corrective action within prescribed time periods, per California Health and Safety Code Sections 1548, 1568.0822, 1569.99. You are hereby notified that a civil penal!~ ~as been assessed. . Crhe above facility has been found in violation of the California Code of Regulations, Title 22, Divisions 6, and/or 12. Section(s) 101238.2 and/or California Health and Safety Code, Chapters 3, 3.01, 3.2, 3.4, and 3.5 Section(s) A Facility Evaluation Report (LIC 809) was issued on violation(s) would result in a civil penalty. D Because you failed to make the corrections specified on the LIC 809, a civil penalty of is assessed for the period from through . 0 !SJ 12/16/2003 giving notice that failure to correct the above A civil penalty of $50 per violation per day, up to a maximum of $150 per day will be assessed. This will continue until correction(s) are made to comply with the licensing Jaws, regulations, and approval of the California Department of Social Servires or auiho•iLdd Jirensing agency. Because you repeated a violation of the same subsection within a 12 month period, an immediate civil penalty of $150.00 is assessed for 09/29/2004, the day the deficiency was cited. zj All Facility Types: Second citation within a 12 month period; an immediate civil penalty of $150 per violation then $50 per day per violation until corrections are made. 0 LJ Residential Care Facility for the Elderly (RCFE), Residential Care Facility for the Chronically ILL (RCF-CJ): Third citation within 12 month period; an immediate civil penalty of $1,000 per violation then $100 per day per violation until corrections are made. 0 Family Child Care Homes (FCCH), Child Care Centers (CCC), Community Care Facility (CCF): Third citation within 12 month period; an immediate civil penalty of $150 per violation then $150 per day per violation until corrections are made. Violations which result in injury, sickness, or death: An immediate civil penalty of $150 per violation and then $150 per day per violation until corrections are made. YOU WILL RECEIVE A BILL IN THE MAIL. DO NOT SEND MONEY UNTIL YOU RECEIVE YOUR BILL! NAME OF LIC lNG PROGRAM ANALYST NAME OF FACIUTY REPRESENTATIVEITITLE SIGNA~~R STAlE OF ":AUFCRNtA- HEAlTH AND HUIAAN SSRV!CES ~ CAliFORNIA DEPARTMENT OF SOC!ALSERVlCES NOTICE OF CIVIL PENALTIES DUE li2l INVOICE NO. 0 Initial Invoice Final Notice DISTRICT OR COUNTY OFFICE NUMBER 0_9_ _ __ 0901008 FACILITY NAME FISCAL YEAR Rancho Heritage School 2004/2005 FACILCTY ADDRESS FAC!L!TYTIPE 9488 Nineteenth Street DCC CITY ""'TE MI"E UC422SENT 12-13-2004 PENAllY PCA CODE 84850 ZIP CODE Rancho Cucamonga. CA 91701 IL~-~-LCTY_8_~_9~_ss _____________________ _j LICENSEE($) OR UNUCENSED FAC!LITY OPSW'OR Rancho Heritage School ADDRESS 9235 Baseline Road STATE CITY ZIP CODE Rancho Cucamonga, CA 91730 The California Health and Safety Code, Sections 1548, 1568.0822, 1569.49, 1596.99, and 1597.62 provides for the imposition of civil penalties against any facility which fails to take corrective action within prescribed time periods. The California Health and Safety Code, Sections 1547, 1568.0821, 1569.485, 1596.89, 1596.891 and 1597.61 provides for. the imposition .of civil penalties against any unlicensed facility which fails to· take corrective action within prescribed time periods. The California Health and Safety Code, Sections 1522, 1568.09, 1569.17, 1596.871, and 1596.8712 provides for the imposition of immediate civil penalties against any facility which fails to comply with fingerprinting or other criminal background rcqukements. Your facility has been found in violation of Community Care Licensing statutes and regulations. Failure to correct the deficiency(ies) cited on the Licensing Report (LIC 809 or LJC 9099) dated__ 9-_2_9-_2_0_04 ___________ has resulted in the following civil penalty assessment of: Penalty Amount Due ..•.................................. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _$,2,50=.0=0 Less Payment(s) Received ................................ ________________________________,.$,0".00~ BALANCE DUE................••....................... _ _ _ _ _ _ _ _ _ _ _ _ __,$,2,5,0.=00 Send the enclosed copy of this notice and your payment to the address shown below within 10 days. MAKE CHECKS PAYABLE TO THE CALIFORNIA DEPARTMENT OF SOCIAL SERVICES. Please write your invoice and facility number(s) on your check. Department of Social Services Community Care Licensing 3737 Main Street, Suite 700 Riverside, CA 92501 FAILURE TO PAY CIVIL PENALTY MAY RESULT IN ANY OR ALL OF THE FOLLOWING: UC 422 • SMALL CLAIMS COURT ACTION • LICENSE DENIAL, SUSPENSION, OR REVOCATION • SEIZURE OF PERSONAL INCOME TAX REFUNDS ~) (PUBUC) STATE OF CALIFORNIA-- HEALTH AND HUMAN SERVICES AGENCY ARNOLD SCHWARZENEGGER, Governor DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING 3737 Main Street, Suite 700 Riverside, CA 92501 (909) 782-4200 10/13/04 Rancho Heritage School 9488 191h St Rancho Cucamonga, Ca 91701 Facility#: 364809859, 364809858 Licensing Report Date: 09/29/04 Dear Licensee: [X] This is to confirm tha! you have cleared the deficiency(ies) cited on the Licensing Report dated 09/2904. No further action on your part is necessary. Thank you for your prompt action. [ ] Verification was either not received or was inadequate to substantiate that the deficiency(ies) cited on the Licensing Report was corrected. You need to provide the following additional documentation/information: 1) 2) 3) Please return a copy of this form and your documentary evidence of correction no later than I I . Failure to provide adequate proof of correction by this date may result in further action as required by regulation. If required to post the Facility Evaluation Report (LIC809) documenting Type A deficiencies, you are also required to post this document verifying your compliance or noncompliance with the Department's order to correct a Type A deficiency. This letter must be posted immediately upon receipt and remain posted for 30 consecutive days. If you have any questions, please feel free to contact me at (909) 782-4202. Sin71y, ~~~~~9 Ll6~~ Kimberly Thomas Licensing Program Analyst Inland Empire Child Care STATE OF CAUFORNIA ~HEALTH AND HUMAN SERVICES AGENCY CAUFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DMSION Inland Empire CC, 3737 Main Street Suite 700 Riverside, CA 92501 COMPLAINT INVESTIGATION REPORT This is an official report of an unannounced visiVinvestigation of a complaint received in our office on 10/08/2004 and conducted by Evaluator Kimberly Thomas COMPLAINT CONTROL NUMBER: 09-CC-20041008144142 FACILITY NAME: DIRECTOR: ADDRESS: CITY: CAPACITY: MET WITH: RANCHO HERITAGE SCHOOL FACILITY NUMBER: 9488 NINETEENTH STREET RANCHO CUCAMONGA FACILITY TYPE: TELEPHONE: ZIP CODE: STATE:CA 79 Complaint CeciliaArce CENSUS:20 UNANNOUNCED 364809858 850 (909) 483-8250 91701 DATE: TIME VISIT BEGAN: TIME COMPLETED: 10/14/2004 02:38PM 04:35PM ALLEGATION($): 1 On 10/5/04 between 2pm and 3pm, teacher Mrs. Mary was observed grabbing two 2-year old children by the 2 arms and shaking them when the children were throwing sand at each other. 3 4 5 6 7 8 9 INVESTIGATION FINDINGS: 1 LPA Kim Thomas arrived at the facility to conduct a complaint investigation regarding the above allegation. 2 LPA interviewed staff and one of the children involved. The teacher involved stated that when a child 3 mibehaves she take them by the arm and talks to them. She stated that she has never shaken a child. Other 4 staff members stated that they have never seen a co-worker inappropriately discipline a child. One of the 5 children involved was interviewed but was very inattentive to the LPA. He stated that he does not recall an 6 incident in which the teacher shook his arms. He stated that staff has grabbed him by the arms but he was 7 unable to determine if it was in a mean manner. From the information received during this investigation, LPA 8 is unable to substantiate or refute the allegations. The above allegation will be inconclusive 9 10 11 12 13 Inconclusive Estimated Days of Completion: """"'""'•' """'' -00 ,., ., )d LICENSING EVALUATOR NAME: """"""" ..,,,_ Kimber~;<~as LICENSING EVALUATOR SIGNATURfr.:i_J) }M. I ' TELEPHONE: (951) 782-4202 fl. 0)');y1/DATE: 10/14/2004 I acknowledge receipt of this form and underl}fi!nd my apffal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: LIC9099 (FAS) ~ (OG/04) ~ ~ DATE: 10/14/2004 Page: 1 of2 STATE OF CAUFORNlA- HEALnt AND HUMAN SERVICES AGENCY CAUFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNI1Y CARE UCENSING DIVISION CIVIL PENALTY ASSESSMENT (Unlicensed and Criminal Background) Inland Empire CC, 3737 Main Street Suite 700 Riverside, ca, CA 92501 DATE FACILITY NAME RANCHO HERITAGE SCHOOL FACIUTY ADDRESS 0210412005 CITY 9488 NINETEENTH STREET STATE RANCHO CUCAMONGA ZIP CODE CA UCENSEE(S}IOPERATOR 91701 FACILITY NUMBER RANCHO HERITAGE SCHOOL 364809858 UNLICENSED FACILITY Civil penalties can be assessed against any unlicensed facility which fails to take corrective action within prescribed time periods, per California Heallh and Safety Code Sections 1547, 1568.03, 1568.0821, 1569.48, and 1598.891. You are hereby notified that a civil penalty has been assessed. Your facility has been found operating without a license. This is in violation of the California Health and Safety Code Sections 1508, 1568.03, 1569.10, or 1596.80. A Notice of Operation in Violation of Law or Denial of Application was issued on giving notice that failure to submit a completed application or cease operation could result in a civil penalty. Because you failed to file a completed application or cease operation, a civil penalty of $0.00 is assessed for the period from through . D 0 Residential Care Facility for the Elderly (RCFE): Since a completed application was not submitted by the 15th day, on day 16 from date of notice or letter, $100 per resident per day is being assessed retroactively. From day 16, $200 per resident per day is being assessed until a completed application is submitted or operations cease {if you have not had a previous application denied). 0 Residential Care Facility for the Chronically Ill (RCF-CI): An immediate civil penalty of $100 per resident per day is being assessed. If a completed application is not submitted by the 15th day, on day 16 from date of notice or letter, $200 per resident per day is being assessed until a completed application is submitted or operations cease (if you have not had a previous application denied). 0 Child Care Center. Family Child Care Home, Community Care Facility: since a completed application was not submitted by the 15th day, on day 16 from the date of notice or letter, $200 per day is being assessed until a completed application is submitted or operations cease (if you have not had a previous application denied). CRIMINAL BACKGROUND CLEARANCE (Immediate) Civil penalties can be assessed for failure to comply with the requirement for fingerprinting and other criminal background requirements, per California Health and Safety Code Sections 1522, 1568.09, 1569.17, 1596.871 and 1596.8712. You are hereby notified that a civil penalty has been assessed. A Facility Evaluation Report (LIC 809) was issued on 02104/2005 giving notice that your facility has been found in violation of the fingerprinting criminal background clearance requirements. :::J $100 Immediate Civil Penalty per person for failure to obtain a DOJ criminal r~cord clearance or an exemption. :sJ $100 Immediate Civil Penalty per person for failure to request that a previously cleared or exempted person be associated to the facility. n $100 immediate Civil Penalty per parent/authorized representative fc. ~ailure to provide "Family Child Care Home Addendum to Notification of Parents' Rights (Regarding Exclusion)". r:J $100 immediate Civil Penalty per parenUauthorized representative for failure to provide "Family Child Care Home Addendum to Notification of Parents' Rights (Regarding Reinstatement)". ;:] $100 immediate Civil Penalty per parenUauthorized representative for failure to obtain signature indicating receipt of Addendum. 0 $100 immediate Civil Penalty for failure to provide signed addendum to the Dep~rtmen\:-;hen requested. flo/>'' Number of Persons X $100 = ' 1 1111 Total Penalty YOU WILL RECEIVE A BILL IN THE MAIL DO NOT SEND MONEY UNTIL YOU RECEIVE YOUR BILL! ~ McMichael-Peirce LIC421A (FAS)- (10(03) Page: 1 cf2 STATE OF CAUFORNtA wHEAL.TH AND HUMAN SERVICES AGENCY CAUFORNlA DEPARTMENT OF SOCIAL SERVlCES COMMUNITY CARE UCENSING DMSION Inland Empire cc, 3737 Main Stroet SUite 700 Riverside, ca, CA 92501 CIVIL PENALTY ASSESSMENT (Unlicensed and Criminal Background) DATE FACILITY NAME RANCHO HERITAGE SCHOOL 02/04/2005 FACILITY ADDRESS CITY 9488 NINETEENTH STREET RANCHO CUCAMONGA STATE ZIP CODE CA 91701 UCENSEE(SVOPERATOR FACIUTY NUMBER RANCHO HERITAGE SCHOOL 364809858 UNLICENSED FACILITY Civil penalties can be assessed against any unlicensed facility which fails to take corrective action within prescribed time periods, per California Health and Safety Code Sections 1547, 1568.03, 1568.0821, 1569.48, and 1598.891. You are hereby notified that a civil penalty has been assessed. Your facility has baen found operating without a license. This is in violation of the California Health and Safety Code Sections 1508, 1568.03, 1569.10, or 1596.80. A Notice of Operation in Violation of Law or Denial of Application was issued on giving notice that failure to submit a completed application or cease operation could result in a civil penalty. Because you failed to file a completed application or cease operation, a civil penalty of So.oo is assessed for the period from through . 0 0 Residential Care Facility for the Elderly (RCFE): Since a completed application was not submitted by the 15th day, on day 16 from date of notice or letter, $100 per resident per day is being assessed retroactively. From day 16, $200 per resident per day is being assessed until a completed application is submitted or operations cease (if you have not had a previous application denied). 0 Residential Care Facility for the Chronically Ill (RCF.CI): An immediate civil penalty of $100 per resident per day is being assessed. If a completed application is not submitted by the 15th day, on day 16 from date of notice or letter, $200 per resident per day is being assessed until a completed application is submitted or operations cease (if you have not had a previous application denied). 0 Child Care Center, Family Child Care Home, Community Care Facility: since a completed application was not submitted by the 15th day, on day 16 from the date of notice or letter, $200 per day is being assessed until a completed application is submitted or operations cease (if you have not had a previous application denied}. CRIMINAL BACKGROUND CLEARANCE (Immediate) Civil penalties can be assessed for failure to comply with the requirement for fingerprinting and other criminal background requirements, per California Health and Safety Code Sections 1522, 1568.09, 1569.17, 1596.871 and 1596.8712. You are hereby notified that a civil penatty has been assessed. A Facility Evaluation Report (LIC 809) was issued on 02/0412005 giving notice that your facility has baen fuund in violation of the fingerprinting criminal background clearance requirements. $100 Immediate Civil Penalty per person for failure to obtain a DOJ criminal record clearance or an exemption. 0 i2J $100 Immediate Civil Penalty per person for failure to request that a previously cleared or exempted person be associated to the facility. 0 $100 immediate Civil Penaity per parenUauthorized representative for failure to provide "Family Child Care Home Addendum to Notification of Parents' Rights (Regarding Exclusion)". 0 $100 immediate Civil Penaity per parenUauthorized representative for failure to provide "Family Child Care Home Addendum to Notification of Parents' Rights (Regarding Reinstatement)". 0 0 $100 immediate Civil Penaity per parenUauthonzed representative for failure to obtain signature indicating receipt of Addendum. $100 immediate Civil Penalty for feilure to provide signed addendum to the Dep~rtmen\ ~en requested. ~ Number of Persons X $100 = ' 11j6( 1 """' Total Penalty YOU WILL RECEIVE A BILL IN THE MAIL. DO NOT SEND MONEY UNTIL YOU RECEIVE YOUR BILL! LIC421A (FAS)- (10103) Page: 1 of2 CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING OMSlON STATE OF CALIFORNIA~ HEALTii AND HUMAN SERVlC:ES AGENCY Jnland Empire CC, 3737 Main Strnet Suite 700 Riverside, ca, CA 92501 FACILITY EVALUATION REPORT (Cont) FACILITY NAME: RANCHO HERITAGE SCHOOL DEFICIENCY INFORMATION FOR THIS PAGE: Deficiency Type POC Due Date I Section Number Type A 02/04/2005 Section Cited 101170 &1596 TypeB Section Cited VISIT DATE: 02/0412005 PLAN OF CORRECTIONS(POCs) DEFICIENCIES 1 2 3 4 5 6 7 Criminal Record Clearance/ Health and Safety Code: Staff members Nora Singh and Diana Camacho have been working at the facility since 01/03/05 and does not have their fingerprints associated to the facility. An immediate assessment of civil penalties in the amount of $100 per violation, per day, for a maximum of 5 days, or for a 1 The Licensee must associate the two 2 staff members to the facility before they 3 are able to continue working at the 4 facility. POC due date 02//04/05. 5 6 7 1 2 3 4 5 6 7 maximum of 30 days in the case of a 2nd or subsequent violation, and by providing that a violation is grounds for denying an application for, or suspending or revoking, a license or administrator certificate. A total of $1,000 dollars will be assessed on todays visit. 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 Failure to correct the cited deliciency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment SUPERVISOR'S NAME: Tammy Michaei-Peirce TELEPHONE: (951)782-4970 LICENSING EVALUATOR NAME: Kimber! Th TELEPHONE: (951) 782-4202 LICENSING EVALUATOR SIGNATURE:.._,""---'--'-':.....!.-'--""--"-"'--'='-""'~ DATE: 02/0412005 I acknowledge receipt of this fonn and unders~f)d "fappe FACILITY REPRESENTATIVE SIGNATURE: UC80iJ (FAS) - (00104) ~ ! DATE: 02/04/2005 Page: 2 of1 STATE OFCAUFORNlA ·HEALTH AND HUMAN SERVICES AGENCY CAUFORNI.A DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DMSIDN Inland Empire CC, 3737 Main Street SUite 700 Riverside, Ca, CA 92501 FACILITY EVALUATION REPORT (Cont) FACILITY NAME: RANCHO HERITAGE SCHOOL DEFICIENCY INFORMATION FOR THIS PAGE: VISIT DATE: 02104/2005 NARRATIVE/COMMENTS 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 • The licensee has been informed that all employees must be associated to the facility. A civil penalty of $100 per person will be assessed for failure to have fingerprints cleared or failure to associate a previously cleared individual to the facility. • A review of staff records on 02/04105 indicates that not all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. • The following civil penalty information was discussed: If a facility is cited for a serious deficiency and then repeats the same violation within a 12 month period, an immediate penalty of $150 shall be assessed and a penalty of $50 per day shall be assessed until the deficiency is corrected. If the facility repeats the same violation for a third time within the same 12 month period, the facility will be cited and assessed an immediate penalty of $150 for that day and $150 per day until the deficiency is corrected. The licensee was advised how to access forms and regulations for Child Care Centers online at www.dss.cahwnet.gov or ccld.ca.gov • The new "Notification of Parent's Rights" (PUB393) poster was provided and the licensee was advised that it must be posted in an area of the facility accessible to parents. The information regarding new legislation with regards to exemptions and Parent's Rights was also provided. • The licensee was notified that violations of the sections pertaining to Parent's Rights sections 101218.1 (b)(8), (c), (d), (e), (e)(1 ), or (e)(2) are subject to three tier civil penalties. See LIC809D for cited deficiencies in accordance with the California Code of Regulations Title 22, Division 12. An exit interview was conducted, appeal rights discussed and a copy of this report was provided. A copy of this report must be made available to the public, at the facility site, for 3 years. 30 31 32 Failure to correct the cited deliciency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. SUPERVISOR'S NAME: Tammy Michaei-Peirce TELEPHONE: (951)782-4970 LICENSING EVALUATOR NAI\IIE: TELEPHONE: (951) 782-4202 Kimbe~s LICENSINGEVALUATORSIGNATURE: I acknowledge receipt of this form and unders FACILITY REPRESENTATIVE SIGNATURE: UC809 (FAS)- {00104) I hl DATE: 02104/2005 hts as explained and received. DATE: 02104/2005 Page: 2of 1 STATE OF CAUFORN!A- HEALTH AND HUMAN SERViCES AGENCY CAUFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENS!NG DMSION Inland Empire CC. 3737 Main Street Suite 700 FACILITY EVALUATION REPORT FACILITY NAME: DIRECTOR: ADDRESS: CITY: Rlvernl®, Ca, CA 92501 RANCHO HERITAGE SCHOOL FACILITY NUMBER: CECILIA ARCE 9488 NINETEENTH STREET RANCHO CUCAMONGA STATE:CA FACILITY TYPE: TELEPHONE: ZIP CODE: CENSUS: 52 DATE: 85 CAPACITY: TYPE OF VISIT: Annual/Required Cecilia Arce MET WITH: 364809858 850 (909) 483-8250 91701 UNANNOUNCED TIME BEGAN: TIME COMPLETED: DEFICIENCY INFORMATION FOR THIS PAGE: 02104/2005 10:15AM 12:30 PM CIVIL PENALTY INFORMATION: COMMENTS/DEFICIENCIES 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Licensing Program Analyst (LPA), Kim Thomas conducted a comprehensive annual visit. • A review of staff records and children's records is not being conducted as part of this evaluation. The licensee will certify that all record requirements have been met. • The licensee is asked to update the following documents, if applicable, and submit to licensing within 30 days: 1.LIC 500 Personnel Report 2.LIC 610 Emergency & Disaster Plan 3.Parent Handbook/ Program CurriculumiAdmission policies and procedures! fee schedule (only if changes have been made) 4.LIC 309 Administrative Organization (only if changes have been made) 5.LIC 308 Designation of Administrative Responsibility (only if changes have been made) 16 17 18 19 20 21 22 23 • - The following items have been posted and are updated where necessary: License Emergency Disaster Plan (LIC610) and Earthquake Preparedness Checklist (LIC9148) Parent's Rights Poster (PUB393) Personal Rights (LIC613A) Child Car Seat Law Menu Failure to correct the cited deliciency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment SUPERVISOR'S NAME: Tammy Michaei-Peirce LICENSING EVALUATOR NAME: Kimberl Th TELEPHONE: (951)782-4970 as TELEPHONE: (951) 782-4202 LICENSING EVALUATOR SIGNATURE: DATE: 0210412005 I acknowledge receipt of this form and undersUJ\'d..WY -~icr::;peal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: UC809 (FAS) • (06ro4) ~ ! DATE: 02/04/2005 Page: 1 of1 STATE OF CAUFORNIA- HEALTit AND HUMAN SERVICES AGENCY CAUFORNtA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSING DIVISION Inland Empire CC, 3737 Main Street Suite 700 COMPLAINT INVESTIGATION REPORT Rlverald&, Ca, CA 92501 This is an official report of an unannounced visit/investigation of a complaint received in our office on 01/31/2005 and conducted by Evaluator Kimberly Thomas COMPLAINT CONTROL NUMBER: 09-CC-20050131121813 FACILITY NAME: DIRECTOR: ADDRESS: CITY: CAPACITY: MET WITH: RANCHO HERITAGE SCHOOL FACILITY NUMBER: CECILIA ARCE 9488 NINETEENTH STREET RANCHO CUCAMONGA FACILITY TYPE: TELEPHONE: ZIP CODE: STATE:CA 85 Complaint Cecilia Arce CENSUS: 52 UNANNOUNCED 36480g858 850 (909) 483-8250 DATE: TIME VISIT BEGAN: TIME COMPLETED: 91701 02/04/2005 10:15AM 12:30 PM ALLEGATION(S): 1 Personal Rights; staff hit a child's cot during nap time with her hand and told the child to if she did not quit 2 crying she would call the police to come and take her away 3 4 5 6 7 8 9 INVESTIGATION FINDINGS: 1 LPA Kim Thomas arrived at the facility to conduct a complaint investigation regarding the above allegation. 2 LPA met with Cecilia Arce and Massie Hazegh and discussed the allegations. LPA interviewed staff and 3 children. It was disclosed that the facility did have a child that cried a lot through out the day. Staff stated that 4 they made every effort to accommodate the child even allowing the child to pick the classroom she wanted to 5 stay in. Staff also stated that the child would cry so loud that she would disrupt the class. Staff stated that the 6 child would be asked to sit in a chair away from the class until she was ready to join the class in their scheduled 7 activity. Staff deny telling the child they would call the police on her if she continued to cry. The children 8 interviewed were children who were in the same classroom as the child. These children were very young and 9 inattentive and unresponsive to the LPA's questions. From the information received during this investigator n, 10 the above allegation will be inconclusive at this time. 11 12 13 Inconclusive Estimated Days of Completion: SUPERVISOR'S NAME: Tammy Michaei-P~irce· TELEPHONE: (951)782-4970 LICENSING EVALUATOR NAME: Kimberl Jh LICENSING EVALUATOR SIGNATURE: . as ., """'-. (~ L. TELEPHONE: (951) 782-4202 i) ).-v. L;V DATE: 02/04/2005 I acknowledge receipt of this form and understand my app;~l rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: UC0099 {FAS)- (06104) 0~· .~ DATE: 02/04/2005 Page: 1 of 1 STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES CIVIL PENALTY LEDGER PAYMENT, REDUCTION, OR WAIVER RECORD INVOICE NO. 0901008 -------------------------- DISTRICT OFFICE NUMBER I 1FACILITY NN.1E DATE LIC 422 SEr.IT '1_:~004~005 I FACIUTY'TYPE 112-13-2004 i FACILITYPCACOOE l_l:l(;C_ ______ _l~_850 _______ FAciLiTYADDRESS 9488 nineteenth Street ----------------STATE CITY i FISCAL YEAR I Rancho Heritage School 09 3-05-2005 ~--~-~----·-· ~- ZiP CODE Rancho Cucamonga, CA 91701 ~-----~-----------·- -----~- j uceNsEE{Sf" ; Rancho Heritage School !ADDRESS -- ·--~------·------------ i 9235 Baseline road l6i:Y [Rancho Cucamonga, CA__91~3()_ STATE --~-- .. DATE -· ------ . _____ _ _AMOUNT $25o.oo CUMULATIVE BALANCE I $250.00 L -------1----3-03-05 $250.50 I $0.00 1 ' ' IPayment 2-- - - - [ -- - ---·--- ·--·-·--- ---·-· !Payment 3 I ' [Payment 4 I"=" . · · ----------------------r~::~ - --- --------· ·- icoMM-EN_T_S_:_____ LIC422A(5:'01) =================~~~~-~--~~~ - ---------------· ------ Rancho Heritage School ADDRESS IDATE SUPERVISOR APPROVAL I i 9235 Baseline Road CITY STATE TITLE ZIP CODE! Licensing Program Supervisor Rancho Cucamonga, CA 91730 The California Health and Safety Code, Sections 1548, 1568.0822, 1569.49, 1596.99, and 1597.62 provides for the imposition of civil 'penalties against any facility which fails to take corrective action within prescribed time periods. The California Health and Safety Code, Sections 1547, 1568.0821, 1569.485, 1596.89, 1596.891 and 1597.61 provides for the imposition of civil penalties against any unlicensed facility which fails to take corrective action within prescritied time periods. The California Health and Safety Code, Sections 1522, 1568.09, 1569.17, 1596.871, and 1596.8712 provides for the imposition of immediate civil penalties against any facility which fails to comply with fingerprinting or other criminal background requirements. Your facility has been found in violation of Community Care Licensing statutes and regulations. Failure to correct the deficiency(ies) cited on the Licensing Report (LIC 809 or LIC 9099) dated~-29-200~---~---­ has resulted in the following civil penalty assessment of: Penalty Amount Due ................... . ···f~. ~-------~-~.....§250.00 r --~--~---jO.OO Less Payment(s) Received ......................... '7".). ... ------~~~~-~--~--$J50_,QQ CK. NO. BALANCE DUE ........................DATE C.j , . .5 ./! :> j0 Send the enclosed copy of this notice and your payment to the address shown below within 1 0 days. MAKE CHECKS PAYABLE TO THE CALIFORNIA DEPARTMENT OF SOCIAL SERVICES. Please write your invoice and facility number(s) on your check. Department of Social Services Community Cara Ucan.:;;ng 3737 Main Street, Suite 700 Riverside, CA 92501 FAILURE TO PAY CIVIL PENALTY MAY RESULT IN ANY OR ALL OF THE FOLLOWING: • SMALL CLAIMS COURT ACTION • LICENSE DENIAL, SUSPENSION, OR REVOCATION • SEIZURE OF PERSONAL INCOME TAX REFUNDS LIC 422 (3102! (PUBLIC) STATE OF CAUFORNtA ~ HEALnl AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCW. SERVICES COMMUNITY CARE UCENSING DMSION FACILITY EVALUATION REPORT (Cont) Inland Empire cc, 3737 Main Street Suite 700 Rlver&lde, ca, CA 92501 FACIUTY NAME: RANCHO HERITAGE SCHOOL DEFICIENCY INFORMATION FOR THIS PAGE: Deficiency Type POC Due Date I VISIT DATE: 02104/2005 DEFICIENCIES PLAN OF CORRECTIONS(POCs) Section Number Type A 02/04/2005 Section Cited 101170 &1596 TypeS Section Cited 1 2 3 4 5 6 7 1 2 3 4 5 6 7 Criminal Record Clearance/ Health and Safety Code: Staff 1 The Licensee must associate the two members Nora Singh and Diana Camacho have been working 2 at the facility since 01/03/05 and does not have their 3 fingerprints associated to the facility. An immediate assessment of civil penalties in the amount of $100 per violation, per day, for a maximum of 5 days, or for a 4 5 6 maximum of 30 days in the case of a 2nd or subsequent violation, and by providing that a violation is grounds for denying an application for, or suspending or revoking, a 1 2 3 4 5 6 7 license or administrator certificate. A tolal of $1,000 dollars will be assessed on todays visit. staff members to the facility before they are able to continue working at the facility. POC due date 02//04/05. 7 1 2 3 4 1 2 3 4 5 6 7 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 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: Tammy Michael-Peirce -.. TELEPHONE: (951)782-4970 LICENSING EVALUATOR NAME: Kimber! Th TELEPHONE: (951) 782-4202 LICENSING EVALUATOR SIGNATURE: DATE: 02/0412005 I acknowledge receipt of this form and unders~?l)d "!tappe,a]!rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: LJCB09 {FAS) • (06/04) ~ /L..z__ DATE: 02/04/2005 Page: 2 of 1 ARNOlD SCHWARZENEGGER, Governor STATE Of CALIFORNIA-HEALTH AND HUMAN SER\IlCES AGENCY DEPARTMENT OF SOCIAL SERVICES 3737 Main Street, Suite 700, Riverside, California 92501 PENALTY REVIEW May27, 2005 Facility Name: Rancho Heritage School Facility Number: 364809858 Rancho Heritage School 9235 Baseline Road Rancho Cucamonga, California 91730 Dear Massie Hazegh: Per your reques~ a review was made of the deficiencies cited in February 2005. I do apologize for any inconvenience that the delay in my response may have caused. In that report, you were cited under Title 22, Section 101170 - Criminal Record Clearance/Health & Safety Code, Section 1596. The citation reads that staff persons Nora Singh and Diana Camacho have been working at the facility since 01/03/05 and they do not have their fingerprints associated to the facility. In your appeal you have stated that your organization faxed, to this department, Diane Camacho's "paper" on 12/02/04 and Nora Singh's "paper" on 12/21/04. You have submitted your Fax Activity Log which clearly shows that you did fax three pages/documents to this office on those dates. Also submitted was a copy of the criminal background clearance transfer request, with identification of fax and date sent. The fact that documentation was faxed to this office on 12/02/04 is not being questioned. You have also submitted a letter sent to the above noted facility on January 11, 2005. With that, you have made the argument that this department took 40 days to respond that there was no picture i.d. submitted with the request to associate Diane Camacho to your facility. The documentation above provides proof that you were notified on January 11, 2005 that the association for Diane Camacho was not completed because we did not have record of a valid picture i.d. Still, on February 4, 2005, 22 days after the fact, you had not complied with our request to submit the picture i.d. to complete the association. Also, after that notification, you continued to allow Ms. Diane Camacho to work with children in your care. In response, I will take this opportunity to remind you that Title 22 Regulations, Section 101170( e )(f)(h) Criminal Record Clearance, clearly states that it is the responsibility of the licensee to make certain that their employees are cleared and associated to the appropriate facilities or they will be subject to civil penalty. In January of 2005, Assembly Bill 1240 amended this regulation to read .. ."$100.00 per day with a maximum of $500.00 per person on the first violation and up to $3000.00 per person on the second violation". FILE C Rancho Heritage Page Two Finally, it was the responsibility of the licensee to call this department and confirm that Ms. Camacho and Ms. Singh were cleared and associated prior to their presence in the aforementioned facility therefore, the citation and the civil penalties will stand. I do appreciate the opportunity to address your concerns regarding this matter. Should you have any further questions, please contact me at (951 )782-4970. u~~ fiz._~ ~-~ ~A~;;~~cMICHAEL-PEIRCE Licensing Program Manager Inland Empire Childcare llE STArE OF CALii-ORNIA- HEALTI-1 Al''TATE CA 91730 LICEtJSEE{S) 'FACILITY NUMBER Rancho Cucamonga School 364809858 , ADDRESS 9235 Baseline Road CITY Rancho Cucamogna STATE CA Zl? CODE 91730 DATE AMOUNT .. CUMULATIVE BALANCE Original Invoice Amount 02/04/05 $1,000.00 . $1,000.00 $1,000.00 $1,000.00 Civil Penalty Waiver Penalty Review Reduction Penalty Review Reduction ·Payment 1 Payment 2 Payment 3 :Payment 4 Payment 5 BALANCE COMMENTS: L!C422Ai5.'01J STATE Of CALIFORNIA- HEALTH AND HUMAN SERVICES AGE. CALIFORNIA OEPAATMENT OF SOCIAL SEfMCES NOTICE OF CIVIL PENALTIES DUE 0 'i2j Initial Invoice INVOICE NO. ~01181 __ Final Notice DISTRICT OR COUNTY OFFICE NUMBER 09 (KT.:_c_l_ _ I'ISCAL YEAR 1 Rancho Heritage School 2004/2005 fACILITY ADDRESS FACILITY TYPE ' 9235 Baseline Road DATE LIC 422 SENT 06/08/05 PENALTY PCA CODE 850 STATE CITY ZIP CODE ' Rancho Cucamonga, CA 91730 FACiLITY MJM~ER 364809858 LICENSEEtSt OR Ut.:LICEt,SED fACILITY OPERATOR , Rancho Heritage School ~fi(W111J. ~tir- t~~/08/05 AOORESS 9235 Baseline Road STATE CITY liPCGOE Rancho Cucamonga, CA 91730 -- :I~LE a \Jlj~ Licensing Program Supervisor The California Health and Safety Code, Sections 1548, 1568.0822, 1569.49, 1596.99, and 1597.62 provides for the imposition of civil penalties against any facility which fails to take corrective action within prescribed time periods. The California Health and Safety Code, Sections 1547, 1568.0821, 1569.485, 1596.89, 1596.891 and 1597.61 provides for the imposition of civil penalties against any unlicensed facility which fails to take corrective action within prescribed time periods. The California Health and Safety Code, Sections 1522, 1568.09, 1569.17, 1596.871, and 1596.8712 provides for the imposition of immediate civil penalties against any facility which fails to comply with fingerprinting or other criminal background requirements. Your facility has been found in violation of Community Care Licensing statutes and regulations. Failure to correct the deficiency(ies) cited on the Licensing Report (LIC 809 or LIC 9099) dated_~~~4/05 - - - - - - - has resulted in the following civil penalty assessment of: Penalty Amount Due ..................................... _____________________________ip,1Jl.QO.Q.Q. Less Payment(s) Received ................................ --------------------------------- $0_,Q.Q. BALANCE DUE ........· ................................. _______________________________:H,9.9.9_,Q.Q. Send the enclosed copy of this notice and your payment to the address shown below within 10 days. MAKE CHECKS PAYABLE TO THE CALIFORNIA DEPARTMENT OF SOCIAL SERVICES. Please. write your invoice and facility number(s) on your check. Department of Social Services ~~~~~ni~~~~~~icensin~----------------3737 Main Street, Suite 700 Riverside, CA 92501 FAILURE TO PAY CIVIL PENALTY MAY RESULT IN ANY OR ALL OF THE FOLLOWING: SMALL CLAIMS COURT ACTION • . )' • LICENSE DENIAL, SUSPENSION, OR REVOCATION • SEIZURE OF PERSONAL INCOME TAX REFUNDS COPY STATE OF CAUFO!'l1JJA HEALTH t-NO H!J1,1Ml SCRVICES ACEf.)CY GALIFOAWA DFJ>ARTMErlT OF SOGIAt SERVICES CIVIL PENALTY LEDGER PAYMENT, REDUCTION, OR WAIVER RECORD INVOICE N0._0_9_01_1_81_ _ _ _ __ DISTRICT OFFICE NUMBER_o9_ __ FISCAL YEAR FACILITY flAME Rancho Heritage School 2004/2005 FACILITY ADDRESS FACILITY TYi'E 9235 Baseline Road OATE LIC 422 SHH 07/13//05 FACILlTY PCA CODE 840 Zif' CODE Rancho Cucamonga CA 91730 FACILITY NUMBER UCENSEEtSJ 364809858 Rancho Cucamonga School ADDRESS 9235 Baseline Road CITY Rancho Cucamogna STATE CA 91730 DATE AMOUNT CUMULATIVE BALANCE Original Invoice Amount 02/04/05 $1,000.00 $1,000.00 $1,000.00 $1,000.00 Civil Penalty Waiver Penalty Review Reduction Penalty Review Reduction Payment 1 Payment 2 Payment 3 Payment 4 Payment 5 BALANCE COMMENTS: STATE OF CAUFORNfA- HEALTH AIUI'I..I{V~:",)Ii l·'L'Il>f<:S~ foi'I'Ho?\'"1. ! 'J•\;~· , • --· . L; 0_9~28/05 /(.t·t:r ,,: I·:'': Pr_i. . :.~l ·;;. !:!..i'. . I 9488 19tl; Street IHU:: Licensing Prog:am Supervisor --- --- ---- ·----- The California Health and Safety Code, Sections 1548, 1568.0822, 1569.49, 1596.99, and 1597.62 provides for the imposition of civil penalties against any facility which fails to take corrective action within prescribed time periods. The California Health and Safety Code, Sections 1547, 1568.0821, 1569.485, 1596.89, 1596.891 and 1597.61 provides for the imposition of civil penalties against any unlicensed facility which fails to take corrective action within prescribed time periods. The California Health and Safety Code, Sections 1522, 1568.09, 1569.17, 1596.871. and 1596.8712 provides for the imposition of immediate civil penalties against any facility which fails to comply with fingerprinting cr other criminal background requirements. Your facility has been found in violation of Community Care Licensing statutes and regulations. Failure to correct the deficiency(ies) cited on the Licensing Report (LIC 809 or LIC 9099) dated~~~O/~~------------­ has resulted in the following civil penalty assessment of: Penalty Amount Due ........................ . ........ ------·--------····--- ________________ _:?_:! 50~Q.Q. . . . . . . . . . . . . . _______________________________S_O.OQ Less Payment(s) Received BALANCE DUE ......................................... _________________________________ j_'l§_Q_,QQ Send the enclosed copy of this notice and your payrr.en: to t11e address shown below within 10 days. MAKE CHECKS PAYABLE TO THE CALIFORNIA DEPARTMENT OF SOCIAL SERVICES. Piease write your invoice and facility number(s) on your check. Department of Social Services Community Care Licensing ----------------------------------3737 Main Street, Suite 700 Riverside, CA 92501 FAILURE TO PAY CIVIL PENALTY MAY RESULT IN ANY OR ALL OF THE FOLLOWING: SMALL CLAIMS COURT ACTION LICENSE DENIAL, SUSPENSION, OR REVOCATION • SEIZURE OF PERSONAL INCOME TAX REFUNDS OCT 05 2005 19:52 9999 PAGE.04 3737 Main street, Sutte 700, Riverside, California 92501 PENAlTY REVIEW November 21, 2005 Facility Name: Rancho Heritage School Facility Number: 364809858 Invoice Number: 0901236 Rancho Heritage School 9488 19th Street Rancho Cucamonga, California 91701 Dear C. Arce: Per your request of October 7, 2005, a review was made of the following Deficiency and/or Penalty Notices: Section 101238.2 Buildings and Grounds which requires cushioning material around and under play structures. The results are as follows: [] [] [] [] [X] Penalty Assessment Dismissed Penalty Assessment Amount amended to $_. Extension of Correction Due Date Approved to __. Extension Date Denied Request Denied November 21, 2005 Date of Review Decision Explanation: Though you have received an approved waiver to use the alternate cushioning material, the request to do so did not come in to this office until after the citation for the use of alternate cushioning material was cited on September 20, 2005. As a result, the citation and the civil penalty associated with the violation will stand. Thank you for according me the opportunity to review this matter. Should you have any future concerns, please contact me at 951-782-4970. ~»z~~l.l::~ TAMMY~cMICHAEL-PEIRCE Licensing Program Manager Inland Empire Childcare FilE COPY CAUFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSING DMSION STATE OF CAUFORNIA- HEALTH AND HUMAN SERVICES AGENCY Inland Empire CC, 3737 Main Street Suite 700 FACILITY EVALUATION REPORT FACILITY NAME: DIRECTOR: ADDRESS: CITY: Riverside, CA 92501 RANCHO HERITAGE SCHOOL FACILITY NUMBER: CECILIA ARCE 9488 NINETEENTH STREET RANCHO CUCAMONGA FACILITY TYPE: TELEPHONE: ZIP CODE: STATE:CA 364809858 850 (909) 483-8250 91701 CENSUS: 42 DATE: UNANNOUNCED TIME BEGAN: TIME COMPLETED: 85 CAPACITY: TYPE OF VISIT: Case Management Cecilia Arce MET WITH: DEFICIENCY INFORMATION FOR THIS PAGE: 12/20/2005 09:45AM 10:30AM CIVIL PENALTY INFORMATION: COMMENTS/DEFICIENCIES 1 2 3 4 5 6 7 LPA Kim Thomas arrived at the facility to conduct a case management visit per the noncompliance conference meeting held on 04/23/02. LPA met with the director, toured the facility and took census. LPA observed children in two classrooms. In the first classroom there were 3 teachers supervising 22 children. In the second classroom, there were two teachers supervising 10 children. LPA also observed one teacher supervising 10 children on the playground. The facility was observed to be within teacher-child ratio. There were no deficiencies observed during this visit and the facility was in compliance with Title 22 regulations. 8 9 Exit interview was held and a copy of this report was provided to the director, Cecilia Arce. 10 This report must be made available to the public for 3 years. 11 12 13 14 15 16 17 18 19 20 21 22 23 / Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessmenl SUPERVISOR'S NAME: Tammy J. McMichaei-P rce LICENSING EVALUATOR NAME: Kimbe I T. omas LICENSING EVALUATOR SIGNATU . TELEPHONE: (951)782-4970 __}__ 1l-lA.-(__ TELEPHONE: (951) 782-4202 J lib ~ DATE: 12120/2005 appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: UCB09(FAS) - {06/04) DATE: 12120/2005 Page: 1 of 1 STATEOFCAUFORNlA ·HEALTH AND HUMAN SERVICES AGENCY CAUFORNIA DEPARTMENT OF SOCIAL SERVJCES COMMUNITY CARE liCENSING OMS!ON Inland Empire CC, 3737 Main Street Strite 700 Riverside, ca. CA 92501 FACILITY EVALUATION REPORT FACILITY NAME: DIRECTOR: ADDRESS: CITY: RANCHO HERITAGE SCHOOL FACILITY NUMBER: CECILIA ARCE 9488 NINETEENTH STREET RANCHO CUCAMONGA FACILITY TYPE: TELEPHONE: ZIP CODE: STATE:CA CAPACITY: 85 TYPE OF VISIT: Case Management MET WITH: MASSIE HAZEGH CENSUS: 54 UNANNOUNCED DEFICIENCY INFORMATION FOR THIS PAGE: No Deficiency Cited 364809858 850 (909) 483-8250 DATE: TIME BEGAN: TIME COMPLETED: 91701 0112712006 12.15 PM IY'> 12:38 PM I~ If\) prn DATE: 01127/2006 Page: 1 of1 CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE liCENSING DIVISION STATE OF CALIFORNIA • HEALTH AND HUMAN SERVICES AGENCY Inland Empire cc, 3737 Main St Ste. 700 Rlv&rslde, ca, CA.92:501 FACILITY EVALUATION REPORT (Cont) FACILITY NAME: RANCHO HERITAGE SCHOOL DEFICIENCY INFORMATION FOR THIS PAGE: Deficiency Type VISIT DATE: 02/09/2006 PLAN OF CORRECTIONS(POCs) DEFICIENCIES POC Due Date I Section Number Type A 02/0912006 Section Cited 101230 1 2 3 4 5 6 7 ActMties/Napping: Observed 1 teacher supervising 19 children during nap time. 7 of the children were awake. A teacher-child ratio of the one teacher supervising 24 napping children is permitted provided that the remaining teachers necessary to meet the overall ratio. The children were just going down for a nap and all of the chfldren mre not yet asleep. 8 9 1 2 3 4 5 6 3 4 5 6 The licensee must submit a staff schedule which includes the days, times and classroom that each staff is going to be in through out the day. This must be submtt to Licensing by 02/09/06. 7 8 9 The facility was previously cited for the same violation on 9/20/05. Since this is a repeat violation within a twelve month 10 period an imme .I DATE: 02/21/2014 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2014 This Notice must be posted for 30 days STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FACILITY EVALUATION REPORT CCLD Regional Office, 3737 MAIN ST., SUITE 700 FACILITY NAME: RANCHO HERITAGE SCHOOL ADMINISTRATOR: ESMERALDA GABRIEL ADDRESS: 948819TH STREET CITY: RANCHO CUCAMONGA 85 CAPACITY: TYPE OF VISIT: Case Management - Deficiencies Hal Hazegh, Esmeralda Gabriel MET WITH: RIVERSIDE, CA. 92501 FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: STATE:CA CENSUS:27 DATE: UNANNOUNCED TIME BEGAN: TIME COMPLETED: 364809858 850 (909) 483-8250 91701 02/21/2014 12:21 PM 01:50PM NARRATIVE LPAs Kim Leung and Aaron Ross conducted comp}tlint investigation at the facility this date. During vis~. LPAs observed a hole of approximately 4 inches b)Ainches in diameter in the grassy area of the playground. Per Vector Control Technician, it resembled ground squirrel hole. That presents tripping hazard and as well as a risk to children's health and safety. In Room 107, LPAs observed an uncovered trash can with cup of milk and food refuse in it. In Room 106, LPAs observed a toaster with significant amount of left over crumbs in tt. Per staff, the toaster has not been in use since 2/18/14. In the same cabinet where the toaster was stored, LPAs observed debris resembled insect droppings. 4 5 6 7 8 See LIC809D for deficiencies cited per California Code of Regulations Title 22, Division 12. 9 10 A probationary license was mailed to the facility on 2/5/14. However, during visit, LPAs noticed that the 11 probationary license was not posted. Another copy of the probationary license was printed at time of visit and 12 13 handed to the facility director to replace the regular license. 14 15 An exit interview was held with the director. A Notice of Site visit was issued and must be posted for 30 days. 16 A copy of this report was provided to the facility. Upon receipt, licensee shall post and provide copies of this 17 licensing report to parents/guardians of children in care at the facility and to parents/guardians of children 18 newly enrolled at the facility during the next 12 months. 19 20 During the extt interview, LPAs advised the facility director to review the Decision and Order which came in 21 effect on 2/3/14. 22 23 This report shall be public record for three years. 24 25 SUPERVISOR'S NAME: Anita Hise TELEPHONE: (951) 782-4200 LICENSING EVALUATOR NAME: Kim Leung TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: ~ c~ "" ..dd·-------~~} r··--.r~ = DATE: 02/21/2014 1 acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2014 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 STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DfVISlON FACILITY EVALUATION REPORT (Cont) CCLD Reglonal Office, 3737 MAtN ST., SUITE 700 RIVERSIDE, CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL DEFICIENCY INFORMATION FOR THIS PAGE: Deficiency Type POC Due Date I Section Number DEFICIENCIES Outdoor Activity Space. Outdoor activity space shall be hazard free. LP ~observed a hole of TypeA ; ; approximately 4 inches b nches in diameter in the 02/24/20; grassy area of the playground. Per Vector Control Technician, it resembled ground squirrel hole. That Section Cited 5 10123B.2(d)(2) 6 presents1 tripping hazard and as well as a risk to children s health and safety. 7 ,j,!; Type A 02/24/2014 Section Cited 101239(ij(1) PLAN OF CORRECTIONS(POCs) Licensee will complete inspection and treatment, if necessary, by a licensed pest control company. Licensee will also fill the hole and conduct playground inspection on a daily basis after inspection and treatment have been completed. Pictures and invoice from licensJpest control will be submitted to CCL by next business day on 2/24/14. Daily inspection Jog will be maintained ~ 1 2 3 4 5 6 7 B 9 10 11 12 13 14 B at the facility and be available for review by 9 Licensing upon request. 10 11 12 13 14 1 2 3 4 Fixtures, Furniture, Equipment and Supplies. All storage containers for solid waste, including moveable bins, shall have tight-fitting covers that are kept on, be in good repair, and shall be 5 leak-proof and rodent-proof. In Room 107, LPAs 6 observed an uncovered trash can with cup of milk 7 and food refuse in it. 1 Type A 02/24/2014 Section Cited 101227(a)(20) FACILITY NUMBER: 364809858 VISIT DATE: 02/21/2014 2 3 4 5 6 7 Food Service. All equipment {fixed or mobile), dishes and utensils shall be kept clean and maintained in safe condition. In Room 106, LPAs observed a toaster with significant amount of left over crumbs in it. Per staff, the toaster has not been in use since 2/18/14. In the same cabinet where the toaster was stored, LPAs observed debris resembled insect droppings. 1 Director will provide in-service training to all staff to 2 ensure all trash cans for solid waste are tightly 3 covered. Proof of training will be submitted to CCL 4 by 2/24/14. 5 6 7 Licensee will ensure strict compliance of regulations on food services. Ucensee will submit 1 written policies and schedule on cleaning cooking 2 utensils and equipment to CCL by 2/24/14. 3 4 5 6 7 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: Anita Hise TELEPHONE: (951) 782-4200 LICENSING EVALUATOR NAME: Kim Leung TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2014 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2014 This Notice must be posted for 30 days STATE OF CALIFORNIA ~HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office 3737 MAIN ST., SUITE 700 RIVERSIDE. CA 92501 02/07/2014 RANCHO HERITAGE SCHOOL 364809858 9488 19TH STREET RANCHO CUCAMONGA, CA 91701 Letter of Deficiency Citations Cleared Dear Licensee, The following deficiencies. initially cited during a visit on 02/04/2014. have been cleared: Section Cited: 101161(a) Plan of Correction: licensee will immediately ceased operating beyond the limitations of !he license. Proof of correction will be submitted to the Department after correction has been made. Date Due: 02104/2014 Corrections: Received memo on policy and rules. Clearance Date: 02/05/2014 Section Cited: 101161(a) Plan of Correction: Date Due: 0210412014 Corrections: Clearance Date: Licensee will immediately ceased operating beyond the limitations of the license. Proof of correction wl[[ be submitted to the Department after correction has been made. Received memo on policy and rules. 02/05/2014 LICENSING EVALUATOR NAME: Kim Leung TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: " ...._ ft?~~s..o-"""_ ... _,7 DATE: 02/07/2014 This report must be available at Child Care and Group Home facilities for public review for 3 years. Cleared POC Letter (FAS) -(04/05) Page: 1 of 2 CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSING DMSION STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY CCLD Regional Office 3737 MAIN ST., SUITE 700 RIVERSIDE, CA 92501 02/07/2014 RANCHO HERITAGE SCHOOL 364809858 COMMENTS Please be advised of the following requirement per California Health & Safety Code: Per Section 1596.8595(b) the licensee shall post the "Letter of Deficiency Citations Cleared" verifying the licensee's compliance or noncompliance with the department's order (LIC809D or LIC 90990) to correct a type A deficiency that is subject to posting for a period of 30 days. The "Letter of Deficiency Citations Cleared" shall be posted immediately upon receipt, immediately adjacent to, the interior side of the main door into the facility and shall be posted for a period of 30 consecutive days. Failure to comply shall result in an immediate civil penalty of one hundred dollars ($1 00). LICENSING EVALUATOR NAME: Kim Leung LICENSING EVALUATOR SIGNATURE: r ~ I TELEPHONE: (951) 529-4713 DATE: 02/07/2014 This report must be available at Child ca/and Group Home facilities for public review for 3 years. Cleared POC Letter (FAS)- (06104) Page: 2 of 2 FiLE COPY STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES NOTICE OF CIVIL PENALTIES DUE IZI D Initial Invoice INVOICE NO. 0903254 Date Sent 211112014 Final Notice REGIONAL OR COUNTY OFFICE NUMBER..:c09:.:.:.1H'-'-10::..::_8_ __ FACILITY NAME FISCAL YEAR Rancho Heritage School 2013/2014 PHYSICAL ADDRESS FACILITY TYPE 9488 19th Street I ~~ATE CITY Rancho Cucamonga 850 ZIP CODE CA MAILING ADDRESS 84035 I FACILITY NUMBER I91701 ~STATE Rancho Cucamonga 0211112014 PENALTY PCA CODE 91701 9488 19th Street CITY DATE LIC 422 SENT 364809858 ZIP CODE CA LICENSEE{S) OR UNLICENSED FACILITY OPERATOR Rancho Heritage School SUPERVISOR APPROVAL ADDRESS A.N. for A. Hise 9488 19th Street On 0210412014 I91701 ICA CITY ZIP CODE STATE Rancho Cucamonga TITLE IDATE Licensing Program Manager I I 0211112014 your facility was found to be in violation of one or more sections of the California Health and Safety Code. DATE See attached LIC 421 series form. As a result, you were assessed the following amount: (DATE) Penalty Amount OriQinally Assessed: 0210412014 $ 150.00 (DATE) $ Penaltv Amount Amended: (DATE) Payment Received: $ Balance Due: $ 150.00 Send a copy of this notice and your payment to the address shown below within 10 days. MAKE CHECKS PAYABLE TO THE CALIFORNIA DEPARTMENT OF SOCIAL SERVICES. Please write your invoice and facility number(s) on your check. To: CIVIL PENALTY COORDINATOR Community Care Licensing 3737 Main Street, Suite 700 Riverside, CA 92501 FAILURE TO PAY CIVIL PENALTY MAY RESULT IN ANY OR ALL OF THE FOLLOWING: • SEIZURE OF PERSONAL INCOME TAX REFUNDS • LICENSE DENIAL, SUSPENSION, OR REVOCATION • COURT ACTION LIC 422 (9111) (PUBLIC) STATE OF CALIFORNIA- HEALTH AND HUMAtJ SERVICES AGENCY CAL!fORtJII\ DEPARTMENT OF SOCIAL SERVICES CIVIL PENALTY LEDGER INVOICE NO._o_go_32_5_4- - - - - - - - - - FACILITY NAME FISCAl YEAR Rancho Heritage School FACILITY ADDRESS 9488 19th Street CITY Rancho Cucamonga REGIONAL OFFICE NUMBER _ 09_1H_10_8_ _ DATE UG 422 SENT 2013/2014 02/11/2014 FACILITY TYPE FACILITY PCA CODE 84035 850 STATE CA liP CODE 91701 I LICENSEE(S) OR UNLICENSED FACILITY OPERATOR FACILITY NUMBER Rancho Heritage School 364809858 I ADDRESS 9488 19th Street CITY Rancho Cucamonga STATE CA 71P CODF 91701 DATE AMOUNT CUMULATIVE BALANCE Original Invoice Amount Assessed 02/04/2014 Civil Penalty Amended Amount Civil Penalty Amended Amount Civil Penalty Amended Amount Sent to Central Operations Branch Payment Payment Payment Payment Payment COMMENTS: UG <122A (10111} $150.00 $150.00 STATE OF CAliFORNIA· HEAl1H ANO HUMAN SERVICES AGENCY CALIFORNIA OEPAATMENT OF SOCIAL SERVICES CIVIL PENALTY ASSESSMENT DAn; FACILITYNAME 02/04/2014 Rancho Heritage Scho_o_l_ _ _ _ _ _ __ FACIUTY ADDRESS 9488 19th Street - - - - , Z I P CODE Rancho Cucamonga, CA 91701 LICENSEE{S)/OPERAr0fi ·~=========- RanChO Heritage School I FACii.rrY 11; 364809858 --·· --------·---· - LICENSED FACILITY Civil penalties can be assessed against any facility which fails to take corrective action within prescribed time periods, per California Health and Safety Code Sections 1548, 1568.0822,1569.49,1596.99, and 1597.58. You are hereby notified that a civil penalty has been assessed. The above facility has been found in violation of the California Code of Regulations, Title 22, Divisions 6, and/or 12, Section(s) _ _ l l L L l J Q J . \ J O J - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - and/or California Health and Safety Code, Division 2, Chapters 3, 3.01, 3.2, 3.4, and 3.5, and 3.6. Section(s) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ A Licensing Report (LIC 809 or LIC 9099) was issued on ------'1"'2,.,11"::6~12:"0w.13,__ _ _ _ _ giving notice that failure to DATE correct the above violation(s) would result in a civil penalty. 0 Because you failed to make the corrections specified on the LIC 809, a civil penalty of $______ is assessed for the period from through - - - - - - - 0 IZl OATE OATE A civil penalty of $50 per violation per day, up to a maximum of $150 per violation per day will be assessed. This will continue until correction(s) is made to comply with the licensing laws, regulations, and approval of the California Department of Social Services or authorized licensing agency. Because you repeated a violation of the same subsection within a 12-month period, an immediate civil penalty of 150 oo is assessed for the period from 02/04/2014 through 02104/2014 $ OATE DATE 0 All Facility Types Except Child Care Centers: Second citation within a 12 month period; an immediate civil penalty of $150 per violation; then $50 per day per violation until corrections are made. IZl Child Care Centers Only: Second citation within a 12-month period; an immediate civil penalty of $150 per violation; then $150 per day per violation until corrections are made. 0 Residential Care Facility for the Elderly (RCFE), Residential Care Facility for the Chronically Ill (RCF-CI): Third citation within a 12-month period; an immediate civil penalty of $1,000 per violation; then $100 per day per violation until corrections are made. 0 Family Child Care Home (FCCH), Child Care Center (CCC), Community Care Facility (CCF): Third citation within 12month period; an immediate civil penalty of $150 per violation; then $150 per day per violation until corrections are made. 0 FCCH and CCC only: Second or subsequent violation for failure to allow parent or guardian to enter and inspect facility or for retaliation/discrimination stemming from a request to enter or lodge a complaint. A civil penalty of $50 per violation. Total Penalty Assessed $ 1.::-o • ,_.-@ YOU WILL RECEIVE AN INVOICE IN THE MAIL. DO NOT SEND MONEY UNTIL YOU RECEIVE YOUR INVOICE "illAME OF LICENSING PROGRAM ANALYST Kim Leung 02/04/2014 =--~ UC421 {7/11) PAGE 1 OF2 STATE OF CAUFORNIA • HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FACILITY EVALUATION REPORT CCLD Regional Office, 3737 MAIN ST., SUITE 700 RIVERSIDE, CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL ADMINISTRATOR: ESMERALDA GABRIEL ADDRESS: 9488 19TH STREET CITY: RANCHO CUCAMONGA 85 CAPACITY: TYPE OF VISIT: Case ManagementLegal/Non-compliance MET WITH: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: STATE:CA DATE: CENSUS: UNANNOUNCED TIME BEGAN: 364809858 850 (909) 483-8250 91701 02/04/2014 TIME COMPLETED: 05:55PM 04:00PM NARRATIVE LPA Kim Leung conducted a case management visit at the facility this date to review the Decision and Order (D & 0) with the licensee. Facility director was not present at the facility at time of visit. Effective 2/3/2014, facility is on probation for 3 years until 2/2/2017. Terms and conditions ofthe D & 0 were reviewed. Licensee Hal Hazegh confirmed that a copy of the D & 0 was received prior to this visit. He agrees to submit annual staff training plan to the Department for approval. Training plan for the current year shall be submitted no later than 4/3/2014. A copy of the Decision and Order was provided to the facility. Printout of the probationary license will be mailed to facility. Upon receipt, facility must post it up at a prominent location of the facility to replace the current license. A school-age child enrolled in the private school upstairs was present in the preschool activity room. Per licensee and staff, the child usually stays in the front office after the private school session in the afternoon. Staff stated that the child has been walking with staff in the preschool facility from activity room to activity when the staff was taking census during the operation of the preschool program. Facility is licensed for providing care to children up to 5 years of age. Facility was operating beyond the limitations of the license by having a school-age child receiving care in the preschool facility from an employee who is working for the preschool program at the time. See LIC809D for deficiency cited per California Code of Regulations Title 22, Division 12. An exit interview was held with the director. A Notice of Site visit was issued and must be posted for 30 days. A copy of this report was provided to the facility. Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. This report shall be public record for three years. 23 24 25 SUPERVISOR'S NAME: Anita Hise TELEPHONE: (951) 782-4200 LICENSING EVALUATOR NAME: Kim Leung TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: ~~------~~·-----}, DATE: 02/04/2014 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: ~ DATE: 02/04/2014 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC609 (FAS)- (06/04) Page: 1 ol2 STATE OF CALIFORNIA~ HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FACILITY EVALUATION REPORT (Cont) CCLD Regional Office, 3737 MAIN ST., SUITE 700 RIVERSIDE, CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL DEFICIENCY INFORMATION FOR THIS PAGE: FACILITY NUMBER: 364809858 VISIT DATE: 02/04/2014 Deficiency Type POC Due Date/ DEFICIENCIES PLAN OF CORRECTIONS(POCs) Section Number Type A 02/04/2014 Section Cited 101161(a) 1 2 3 4 5 6 7 Umitations on Capacity and Ambulatory Status. The licensee shall not exceed the conditions, limitations and capacity specified In the license. A school~age child enrolled in the private school upstairs was present in the preschool activity room. Per licensee and staff, the child usually stays in the front office after the 8 private school session in the afternoon. Staff 9 10 11 12 13 14 Type A 02/04/2014 Section Cited 101161 (a) 1 2 3 4 5 6 7 stated that the child has been walking with staff in the preschool facility from activity room to activity when the staff was taking census during the operation of the preschool program. Facility is licensed for providing care to children up to 5 years of age. Facility was operating beyond the limitations of the license by having CONTINUATION a school-age child receiving care in the preschool facility from an employee who is working for the preschool program at the time. That was a repeat violation. Facility was cited for the same violation on 12/16/13. PROGRESSIVE CIVIL PENALTY WILL BE ASSESSED. 1 2 3 4 5 6 7 1 Ucensee will immediately ceased operating beyond 2 the limitations of the license. Proof of correction 3 will be submitted to the Department after correction 4 has been made. 5 6 7 8 9 10 11 12 13 14 1 2 3 4 5 6 7 Ucensee will immediately ceased operating beyond the limitations of the license. Proof of correction will be submitted to the Department after correction has been made. 1 2 3 4 5 6 7 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: Anita Hise TELEPHONE: (951) 782-4200 LICENSING EVALUATOR NAME: Kim Leung TELEPHONE: (951) 529-4713 ., LICENSING EVALUATOR SIGNATURE: t!.,/~:!ii!P~w•.-:::;~ • .........- ) DATE: 02/04/2014 1 acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2014 This Notice must be posted for 30 days LIC809 (FAS) - (06/04) Page: 2 of 2 CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DMSION STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY CCLD Regional Office 3737 MAIN ST., SUITE 700 RIVERSIDE, CA 92501 01/02/2014 RANCHO HERITAGE SCHOOL 364809858 9466 19TH STREET RANCHO CUCAMONGA, CA 91701 Letter of Deficiency Citations Cleared Dear Licensee, The following deficiencies, initially cited during a visit on 12/16/2013, have been cleared: Section Cited: 10123B(g) Date Due: 12/17/2013 Plan of Correction: Corrections: Clearance Date: The Licensee must make all of the items inaccessible to the daycare children and proof of the correction must be submitted to the Department b 12/17/13. Received email on 12/17/13 and 12/17/2013 Section Cited: 101161(a) Date Due: 12/17/2013 Plan of Correction: The Licensee must submit a written statement by 12.17.13 ensuring the Department that he understands the seriousness of this citation and he's plan to comply with the Regulations. Corrections: LICENSING EVALUATOR NAME: Aaron Ross received proof of pictures on 12/28/13. Clearance Date: Received email on 12/17/13 and 12/17/2013 received proof of pictures on 12/28/13. TELEPHONE: (951)-233-7183 LICENSING EVALUATOR SIGNATURE: ~~ DATE: 01/02/2014 This report must be available at Child Care and Group Home facilities for public review for 3 years. Cleared POC Letter (FAS) • {04105) Page: 1 of 1 Private Schools Affidavit Confirmation (CA Dept of Ec' ')n) 10/23/13 2:08PM '/'' EDUCATION --------------- Private School Affidavit Confirmation 2013-14 (covers the period October 1, 2013 through September 30, 2014) Thank you for submitting your Private School Affidavit online. This is your Private School Affidavit Confirmation. Please print this page, and maintain a hardcopy for a period of three years. Do NOT mail a copy to the California Department of Education. ' 'cc .··· ('' ' ... 10/23/2013 2:07:56 PM 145651 10/23/2013 2:07:56 PM From Education Code Section 48222: Yes This is"... a private full-time ... school ... [that] ... offer[s] instruction in the several branches of study required to be taught in public schools of the state, ... [that offers this] instruction ... in English[, and that keeps] ... attendance [records] ... " • School Information 1. Name of School Rancho Heritage School 2. CDE-assigned 14 digit CDS code if 36675956200612 one was previously assigned 3. County in which school is located San Bernardino 4. Public school district in which school is located Alta Lorna SD 5. Street Address (P.O. Box is not acceptable 9488 19th Street 6. City Rancho Cucamonga, CA 91701 - 7. School Telephone Number 909-483-8250 8. Optional School Fax Number -- 9. School E-mail Address hhazegh@rhs-edu.org 10. Optional School E-mail Address 11. Optional School Web Site Address 12. Mailing Address (only if different http://www3 .cde.ca.gov/psa/ submit_form.asp Page 1 of S Private Schools Affidavit Confirmation (CA Dept of Eel 10/23/13 2:08PM 1n) from #5 above) 13. Mailing City (only if#12 has response) Rancho Cucamonga, 91701 - 14. Type of School Coeducational 15. School Accommodations Day Only 16. This school is a certified Nonpublic, Nonsectarian School Yes 17. Grade Span offered Lowest: K 18. High School Diploma Offered No 19. Classification of school Non-Religious Highest: 1 Prior Year School Information 20. Has this school ever filed a Private No School Affidavit under a different school name? 21. Former name of school (if "Yes" answered to previous question) 22. Has this school changed public school districts? No 23. Former public school district (if "Yes" answered to previous question) Statistical Information 24. Range of students' ages * (Youngest may be no younger than 4 years and 9 months) Youngest: 4 years, 9 months Oldest: 6 25. Enrollment on a single date between October 1-15, 2013. If school was not operating during this period, enter enrollment on a single date during current month. * Grade (NOTE: Do not report pre-school enrollment; pre-schools that do not offer kindergarten should not file this PSA.) Number of Pupils Kindergarten 5 First Grade 5 Second Grade 0 Third Grade 0 fourth Grade 0 Fifth Grade 0 Sixth Grade 0 Seventh Grade 0 Eighth Grade 0 Ninth Grade 0 Tenth Grade 0 Eleventh Grade 0 Twelfth Grade 0 Ungraded Elementary 0 Ungraded Secondary 0 Total Enrollment 10 26. Number of Twelfth Grade 0 http://WWW3.cde.ca.gov /psa/ submit_form.asp Page 2 of S Private Schools Affidavit Confirmation (CA Dept of Ed ?n) 10/23/B l:U!S PM Graduates in 2012-2013 School Year 27. Number of School Staff Staff Type Number of Staff Full-time Teachers 3 0 Part-time Teachers Administrators 0 Other Staff 0 "Other Staff'' includes instructional aides, therapists, secretaries, etc. Administrative Staff 28. Site Administrator Mr. Hal Hazegh 29. Site Administrator Title Principal 30. Site Administrator E-mail Address hai@RHS-Edu.org 31. Director or Principal Officer Name Mr. Hal Hazegh 32. Director or Principal Officer Position Principal 33. Director or Principal Officer Address 9488 19th Street 34. Director or Principal Officer City Rancho Cucamonga, CA 91701 - 35. Director or Principal Officer E-mail Hai@RHS-Edu.org Address School Records The person named as Custodian of Records below maintains attendance records required by EC Section 48222 and the records of courses of study, names, addresses, and educational qualifications of the faculty, as required by subdivisions (f)(2) and (3) of EC Section 33190. Such records are true and accurate and are accessible at the place or through the person listed here. 36. Name of Individual who is Custodian of Records Mr. Hal Hazegh 37. Address (Location of Records) 9488 19th St 38. City Rancho Cucamonga, CA 91701 - 39. E-mail Address Hai@RHS-Edu.org Tax Status of School 40. Tax-exempt, nonprofit status under Section 501 (c)(3) of the 1954 U.S. Internal Revenue Code- NO 41. Tax-exempt, nonprofit status under Section 23701 d of the California Revenue and Taxation Code - NO 42. Property tax exemption under Section 214 of the California Revenue and Taxation Code- NO 43. None of the above -YES Acknowledgements and Statutory Notices "YES" indicates your understanding oft he statement and your school's compliance. h n p: //W'WW 3.cd e.ca.g ovIpsa I subm it_form. asp Page 3 of 5 m) Private Schools Affidavit Confirmation (CA Dept of Ed 10/23/13 2:08PM 44.YES All Private School Affidavits are public documents viewable by the public. 45.YES The Private School Affidavit must be filed by persons, firms, associations, partnerships, or corporations offering or conducting full-time day school at the elementary or high school level for students between the ages of six and eighteen years of age. 46.YES Preschools should contact the Community Care Licensing Division (CCLD) of the California Department of Social Services. Contact CCLD at 916-229-4530 or contact a regional office. 47.YES The Affidavit is not a license or authorization to operate a private school. 48.YES The Private School Affidavit does not indicate approval, recognition, or endorsement by the state. Filing of this Affidavit shall not be interpreted to mean, and it shall be unlawful for any school to expressly or impliedly represent by any means whatsoever, that the State of California, the Superintendent of Public Instruction, the State Board of Education, the CDE, or any division or bureau of the Department, or any accrediting agency has made any evaluation, recognition, approval, or endorsement of the school or course unless this is an actual fact (see EC Section 33190). 49.YES Private school authorities are responsible for initiating contact with the appropriate local authorities (city and/or county) regarding compliance with ordinances governing health, safety and fire standards, business licensing, and zoning requirements applicable to private schools. 50.YES When a school ceases operation, every effort should be made to give a copy of pupils' permanent records to parents or guardians. If records cannot be given to the parents or guardians, it is recommended that the school's custodian of records retain the records permanently so that former pupils may obtain copies when needed for future education, employment, or other purposes. 51.YES Retain a copy of this document for a period of three years. 52. YES Filing a Private School Affidavit is not equivalent to obtaining accreditation. A Private School Affidavit does not signify that any accrediting agency has made any evaluation, recognition, approval, or endorsement of the school or courses offered by the school. 53. YES A private school shall not employ a person who has been convicted of a violent or serious felony or a person who would be prohibited from employment by a public school district pursuant to EC Section 44237. This school is in compliance with EC Section 44237 to the extent that it applies. 54. YES The students enrolled in this private school and included in the school's enrollment total are full-time students in this school and are not enrolled in any other public or private elementary or secondary school on a full-time basis. Electronic Signature By submitting this form and the electronic signature attached hereto, I declare under penalty of perjury and the laws of the State of California that I am the owner or other head of the school, and the information contained herein is true, accurate, and complete. Name of owner or other head of school Hal Hazegh Title Principal Telephone Number 909-483-8250 Electronic Signature - Birth Month ••••• Not displayed for security purposes Electronic Signature - Birthday **"*Not displayed for security purposes Electronic Signature - Question What is your favorite sport? Electronic Signature -Answer ****' Not displayed for security purposes . ,_~ i '. ' 10/23/2013 2:07:56 PM 145651 I .. 10/23/2013 2:07:56 PM Confirmation message sent to hhazegh@rhs-edu.org. Confirmation message sent to Hai@RHS-Edu.org. http://www3.cde.ca.gov/psa/ submit_form.asp Page 4 of 5 STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY CAUFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSING DIVISION FACILITY EVALUATION REPORT CCLD Regional Office, 3737 MAIN ST., SUITE 700 RIVERSIDE, CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL ADMINISTRATOR: ESMERALDA GABRIEL 948819TH STREET ADDRESS: CITY: RANCHO CUCAMONGA 85 CAPACITY: TYPE OF VISIT: Annual/Required Esmeralda Gabriel MET WITH: FACILITY NUMBER: FACILITY TYPE: TELEPHONE: STATE:CA ZIP CODE: CENSUS: 20 DATE: UNANNOUNCED TIME BEGAN: TIME COMPLETED: 364809858 850 (909) 483-8250 91701 12/16/2013 12:50 PM 04:40PM NARRATIVE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Licensing Program Analysts (LPAs), Aaron Ross and Ana Noble conducted a comprehensive annual visit. LPAs toured the facility, took census, met with the Center Director. LPAs observe 29 children, however 9 of which were attending the private school. The Licensee stated that the private school hours are from 8:30am to 3pm. The Licensee provided LPAs with a copy of the Private School Affidavit Confirmation for 2013-2014 is. • A review of a sampling of the staff records and children's records were conducted as part of this evaluation. See Children's Records Review (LIC857) and Staff Records Review (LIC859) • The licensee is asked to update the following documents, if applicable, and submit to licensing within 30 days: · 1.LIC 500 Personnel Report 2.LIC 610 Emergency & Disaster Plan 3.Parent Handbook/ Program Curriculum/Admission policies and procedures/ fee schedule (only If changes have been made) 4.LIC 309 Administrative Organization (only if changes have been made) 5.LIC 308 Designation of Administrative Responsibility (only if changes have been made) • The following items have been posted and are updated where necessary: License Emergency Disaster Plan (LIC61 O) and Earthquake Preparedness Checklist (LIC9148) Parent's Rights Poster (PUB393) Personal Rights (LIC613A) Child Car Seat Law Menu Last fire drill conducted on 11/20/13 SUPERVISOR'S NAME: Anita Hise TELEPHONE: (951) 782-4200 LICENSING EVALUATOR NAME: Aaron Ross TELEPHONE: (951)-233-7183 LICENSING EVALUATOR SIGNATURE: ~ DATE: 12/16/2013 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2013 This report must be available at Child Care and Group Home facilities for public review for 3 years. L\C609 (FAS) - (06{04) Page: 1 of 4 STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISlON FACILITY EVALUATION REPORT (Cont) CCLD Regional Office, 3737 MAfN ST., SUITE 700 RIVERSIDE, CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL FACILITY NUMBER: 364809858 VISIT DATE: 12/16/2013 NARRATIVE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 • The licensee has been informed that all employees must be associated to the facility. If the licensee fails to have proof of a fingerprint clearance or fails to associate a previously cleared individual to the facility, a civil penalty of $100.00, per day the person has been present, will be assessed. The first violation is subject to the penalty for up to five days. If there is a subsequent violation in a 12 month period, the fine will continue for up to 30 days. • A review of staff records on 12/16/13 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. • The facility representative was advised that the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days. If a serious violation is cited, a copy of the licensing report (LIC809 or LIC9099) must also be posted for 30 days. If these requirements are not met, civil penalties in the amount of $100 per violation will be assessed. • AB 978- Zero Tolerance Related Regulations went into effect January 18, 2011 -In accordance with California Health and Safety Code Section 1596.99(c)/1597.58(c)- it was explained that an immediate $150 Civil penalty will be assessed for each serious violation and a civil penalty of $150 per day per violation will be assessed until corrected. • AB 2084- Nutritious Beverages in Child Care Facilities went into effect January 1, 2012- In accordance with California Health and Safety Code Section 1596.808- licensee was informed of this new law during this visit. - CPR and 1st Aide cards expired on 12/2015. - Medication is not currently being kept at the facility. See LIC8090 for cited deficiencies in accordance with the California Code of Regulations Title 22, Division 12. An exit interview was conducted, appeal rights discussed and a copy of this report was provided. LICENSING EVALUATOR NAME: Aaron Ross TELEPHONE: (951)-233-7183 LICENSING EVALUATOR SIGNATURE: ~c4~ DATE: 12/16/2013 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2013 Ltc809 (FAS)- (06/04) Page: 3 of 4 STATE OF CAUFORNIA· HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FACILITY EVALUATION REPORT (Cont) CCLD Regional Office, 3737 MAIN ST., SUITE 700 RIVERSIDE, CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL FACILITY NUMBER: 364809858 VISIT DATE: 12/16/2013 DEFICIENCY INFORMATION FOR THIS PAGE: Deficiency Type POC Due Date I DEFICIENCIES PLAN OF CORRECTIONS(POCs) Section Number Type A 12/17/2013 Section Cited 101 238(g) 1 2 3 4 5 6 Section Cited 101161(a) located on the playground. LPAs observed large thrones on and around the tree. LPAs observe a 7 large amount of debris, wood pieces, cement 5 6 7 12 13 14 8 9 10 11 12 13 14 1 2 3 4 5 6 7 1 2 3 exceed the conditions, limitations and capacity specified in the license. The Licensee has enrolled 4 5 Child #3 into the facility private school program between the hours 8:30am and 3pm. The Licensee 6 7 was granted a license from 8 9 10 11 Type A 12/17/2013 1 The Ucensee must make all of the items BUILDINGS AND GROUNDS: Disinfectants, cleaning solutions, poisons and other items that are 2 inaccessible to the daycare children and proof of 3 the correction must be submitted to the dangerous to chlldren.shall be inaccessible to 4 Department by 12/17/13. children. LPAs observed a lemon tree that is blocks, dry leaves, nails, and plastic pipes. AU of the items where located on the side of the storage building located on the field that the children utilize for Physical Education. LIMITATIONS ON CAPACITY AND AMBULATORY STATUS: The licensee shall not 8 Department to provide care to children ages 9 18months to 5yrs old. Child #3 is 6yrs old and 10 remains in care beyond 3pm. LPAs observed the 11 child in care during todays visit after 3pm. 12 13 14 The Ucensee must submit a written statement by 12.17.13 ensuring the Department that he understands the seriousness of this citation and he's plan to comply with the Regulations. tVA:'i 8 9 10 11 12 13 14 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: Anita Hise TELEPHONE: (951} 782·4200 LICENSING EVALUATOR NAME: Aaron Ross TELEPHONE: (951}-233-7183 LICENSING EVALUATOR SIGNATURE: ~~ DATE: 12/16/2013 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2013 This Notice must be posted for 30 days UC809 {FAS)- (06/04) Page: 2 of 4 STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DMSION FACILITY EVALUATION REPORT (Cont) CCLD Regional Office, 3737 MAIN ST., SUITE 700 RIVERSIDE, CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL DEFICIENCY INFORMATION FOR THIS PAGE: Deficiency Type POC Due Date I FACILITY NUMBER: 364809858 VISIT DATE: 12/16/2013 DEFICIENCIES PLAN OF CORRECTIONS(POCs) Section Number TypeS 12/20/2013 Section Cited 101212(c) 1 2 3 4 REPORTING REQUIREMENT: The Ucensee is currently utilizing licensed classroom #1 08 for a private school between the hours of 8:30am to 3pm. The licensee must notify the Department in 5 writing of The Ucensee failed to notify the 6 Department that the classroom is being used for a 7 private school. 8 The Ucensee failed to notify the Department that 9 the classroom is being used for a private school. 1 2 3 4 The licensee must submit a written statement by 12/20/13 ensuring the Department that he has reviewed Title 22 regulations pertaining to this violation and understands the seriousness of this 5 citation. 6 7 8 10 11 12 13 14 9 10 11 12 13 14 1 2 3 4 1 2 3 4 5 5 6 7 6 7 1 2 3 4 1 2 3 5 5 6 7 6 7 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. SUPERVISOR'S NAME: Anita Hise TELEPHONE: (951) 782-4200 LICENSING EVALUATOR NAME: Aaron Ross TELEPHONE: (951)-233-7183 LICENSING EVALUATOR SIGNATURE: r~~ DATE: 12/16/2013 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2013 LIC609 (FAS)- {06/t)4) Page: 4 of 4 STATE OF CALifORNIA· HEALTH ANO HUMAN SERVICES AGENCY CALIFORNIA OEPARThiENT OF SOCl"'L SERVJCES FACILITY VISIT CHECKLIST CHILD CARE CENTERS AND INFANT CENTERS Review facility file prior to visit. Check to see that the following information has been updated, if required, and contained in the file. Indicate the date the information was submitted to the licensing agency in the space provided for each item requested LICENSE ANNIVERSARY DATE . Criminal Record Clearance and Child Abuse Index Checks (LIC 198) (updated for current staff subject to fingerprint requirements} Licensee Affidavit Regarding Persons Exempt From Fingerprint Requirements (if not on LIC 500) Administrative Organization (LIC 309)' .... I / Application Information (LIC 215) ---------··--·---·· Estimated Monthly Operating Budget (LIC 401 ), Budget Information (LIC 420), Financial ....§tatement and Information (L~C 403, LIC 404) I DATE REQUESTED ON FILE / DATE I RECEIVED ; ·-1 -- I' -- I f.--·-- -·--· l / +-··-·· -~---·- / Articles of Incorporation, Constitution and Bylaws (if applicable) --·-·-------· . Partnership Agreement (if applicable) Personnel Report (LIC 500) Updated' -·--------· ____ ··- Facility Floor/Plot .. Plan (LIC 999) ·---··--·-·-- Verification of Qualifications of Facility Director . i r- Designation of Administrative Responsibility (LIC 308)' ·--- __ __ ..- --~----Ylfh:- --· ""-:~-·-r,/ Emergency Disaster Plan (LIC 61 0) ' ·- (!---~ ! {Y( : Disaster and Fire Drills (every 6 months) . -· I / .. Health Screening Report· Facility Personnel (LIC 503) / Daily Activity Schedule / Fire Clearance (consistent with terms and limitations of license) Bacteriological Analysis of Private Water Supply (if applicable) License Fee Received / NOTES AND COMMENTS LIC9tt6(11i0l) *Other verifying documents may be substituted for these LIC forms ... '.. - - - - · ..-- Policies and Procedures!Fee Schedule _______ · -Admissions - -·· 1 ----· Plan of Operation ·- I I I --· j . \ ' ' .! . ·- STATE OF CALIFORNIA¥ HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION NONCOMPLIANCE CONFERENCE SUMMARY CCLD Regional Office, 3737 MAIN ST., SUITE 700 RIVERSIDE, CA 92501 NAME AND ADDRESS OF FACIUll': RANCHO HERITAGE SCHOOL 9488 19TH STREET RANCHO CUCAMONGA, CA 91701 FACILITY LICENSE NUMBER EFFECTIVE DATE OF LICENSE: LICENSE CAPACITY: 02/20/2002 364809858 STATUS: FACILITY TYPE: 3 85 850 LICENSEE NAME(S). RANCHO HERITAGE SCHOOL NAME AND FACILITY NUMBER OF OTHER COMMUNITY CARE, CHILD DAY CARE, RESIDENTIAL CARE FACILITIES FOR THE ELDERLY, OR HEALTH FACILITIES LICENSED TO OR OWNED BY APPLICANT(S) WITHIN THE LAST FIVE YEARS. FACILITY NAME FACILITY NUMBER A. B. c. D. E. F. DATE OF CONFERENCE: 07/10/2012 LICENSING PROGRAM ANALYST: LICENSING PROGRAM MANAGER: Marianne Donley Kim Leung Present at meeting: NAME TITLE Reynauldo Pennywell Marianne Donley Kim Leung Hassan Hazegh Mastaneh Hazegh Regional Manager Licensing Program Manager Licensing Program Analyst Licensee Facility Director LIC9111 (FAS). (12/99) ·(PUBLIC) Page: 1 of STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION NONCOMPLIANCE CONFERENCE SUMMARYPAGE2 CCLD Regional Office, 3737 MAIN ST., SUITE 700 RIVERSIDE, CA 92501 NAME AND ADDRESS OF FACILITY: RANCHO HERITAGE SCHOOL 9488 19TH STREET RANCHO CUCAMONGA, CA 91701 FACILITY LICENSE NUMBER: EFFECTIVE DATE OF LICENSE: 364809858 02/20/2002 LICENSE CAPACITY: STATUS: 85 FACILITY TYPE: 3 850 LICENSEE NAME(S): RANCHO HERITAGE SCHOOL This Noncompliance Conference was called to discuss the following issues or deficiencies: 6/20/2012 Complaint. Case Management 101223(a)(2) Personal Rights- On 6/13/2012, a child was left alone on the playground for at least 8 minutes. Staff members were unaware of the child's whereabout until a passer-by who found the child crying on the playground brought the child back to the front office. Facility failed to ensure the child's safety while the child was receiving care at the facility. Same violation cited on 9/1/2011. Progressive civil penalty assessed. 101229(a)(1) Lack of Supervision- On 6/13/2012, a child was left alone on the playground for at least 8 1 minutes after teacher escorted other children of the class back to the activity room from the playground at 2 approximately 4:30pm. The child was found crying on the playground, alone, by a passer-by. The passer-by 3 talked to the child through the fence, entered the playground through one of the gates, and brought the child to 4 the assistant director who was at the front office between 4:38pm and 4:40pm. Same violation cited on 9/1/2011. 5 Progressive civil penalty and zero tolerance civil penalty assessed. 6 101212(d) Reporting Requirements- A child was left alone on the playground on 6/13/2012. Licensee failed to 7 report the incident to the Licensing. Same deficiency cited on 9/1/2011. Progressive civil penalty assessed. 8 101163(a) False Claims -A child was left alone on the playground on 6/13/2012 and was brought back to the 9 office by a passer-by. During the investigation process, LPA was provided with misleading information in regards 1o to how the child was brought back to the office. Licensee Hal Hazegh stated that misleading information was 11 also provided to him in the same manner by facility staff and therefore the same information was provided to the 12 child's parent. POC NOT RECEIVED. 13 14 213/2012 Case Management 15 101171(a) Fire Clearance- Facility was using the second level of the building for2 hours each day for preschool 16 dance activities. The Department did not approve or license the second level of the building for preschool-age 17 children and there is no fire clearance allowing preschool children to use any area upstairs. On 1/20/2012, while 18 using one for the rooms upstairs, a child tripped when the child was about to walk up the stairs to the auditorium. 19 The child fell face down, hit against the stairs, broke the front tooth and received cuts on the lips. Zero tolerance 20 civil penalty and $150 per day for violation resulting in injury assessed. 21 22 1/5/2012 Required Visit 23 101226(e)(2) Health-Related Services- Prescription inhaler stored at the facility is not labeled with child's name 24 and the inhaler has expired in June 2011. 25 26 9/1/2011 Case Management 27101229(a)(1) Lack of Supervision, 101212(d) Reporting Requirements- A child was left alone on the 28 playground on 7/19/2011 after outdoor activities. Teacher was not aware of missing one child from the group 29 until another staff member stepped in the room to take census. The child was found alone on the playground 30 after approximately 3 to 5 minutes. Licensee failed to report the incident to Licensing as required. 31 32 911/2011 Complaint 101223(a)(2) Personal Rights, 101239(n) Fixtures, Furniture, Equipment and Supplies- The two toilet seats in the two's bathroom appeared to be wobbly that the seats moved approximately two inches to each sides of the toilet. On 7/18/2011, a child had the thigh pinched between the toilet seat and the rim of the toilet. 1/6/2011 Noncompliance Conference to review violations including repetitive lack of supervision, out of ratio, criminal record clearances, teacher qualifications and building and grounds. LICENSEE SIGNATURE DATE: STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION NONCOMPLIANCE CONFERENCE SUMMARYPAGE3 CCLD Regional Office, 3737 MAIN ST., SUITE 700 RIVERSIDE, CA 92501 NAME AND ADDRESS OF FACILITY: RANCHO HERITAGE SCHOOL 9488 19TH STREET RANCHO CUCAMONGA, CA 91701 FACILITY LICENSE NUMBER: EFFECTIVE DATE OF LICENSE: 364809858 02/20/2002 LICENSE CAPACITY: STATUS: 85 FACILITY TYPE; 850 3 LICENSEE NAME{S): RANCHO HERITAGE SCHOOL Licensee agreed to do the following in order to bring the facility into compliance no later than the following dates: 1 IMMEDIATELY 2 Licensee representatives, Hassan Hazegh and Mastaneh Hazegh, agree to operate the facility in full 3 compliance with Title 22 and Health & Safety Code requirements with particular attention to the ~ following sections: 101229 Responsibility for Providing Care and Supervision, 101223 Personal 6 Rights, 101163 False Claims, 101171 Fire Clearance, 101239 Fixture, Furniture, Equipment and 7 Supplies, 101212 Reporting Requirements, and 101226 Health-Related Services. Any further violation 8 of these laws and regulations may result in initiation of proceedings to revoke the Rancho Heritage 9 School license. 10 11 • Proof of correction for deficiency cited under Section 101163 False Claims was not received. It went ~~overdue after 612112012. Licensee representatives agree to submit all pending proof of correction no 14 1aterthan 711112012. 15 16 • Licensee representatives agree to submit a written compliance plan to the Department by 7124/2012 17. 18 19 • Licensee representatives agree to provide all staff members with training on supervision and ~~ personal rights. The training is to be provided by outside vendor. Proof of enrollment will be submitted 22 to the Department by 8/1012012. Proof of training including training agenda, material and sign in 23 sheets will be submitted to the Department by 9/10/2012. 24 25 • Licensee representatives agree to have all facility employees hired after January 2011 complete the 26 Child Care Center Orientation Component Ill. Orientation Certificates will be submitted to the ~~ Department by 12/31/2012. ~~ • Licensee representatives were informed that this facility would be referred to the Legal Division for 31 possible administrative actions. 32 LICENSEE SIGNATURE DATE: 07/10/2012 MANAGER SIGNATURE: DATE: 07/10/2012 LIC9111 {FAS) • {12/99)- (PUBLIC) Page: 4 of4 STATE OF CAliFORNIA· HEALTH AND HU, __. .;ERVICES AGENCY CALIFORNIA .... , nRTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION NONCOMPLIANCE CONFERENCE SUMMARYPAGE4 CCLD Regional Office, 3737 MAIN ST., SUITE 700 RIVERSIDE, CA 92501 NAME AND ADDRESS OF FACILilY: RANCHO HERITAGE SCHOOL 9488 19TH STREET RANCHO CUCAMONGA, CA 91701 FACILITY LICENSE NUMBER: EFFECTIVE DATE OF LICENSE: 364809858 02/20/2002 LICENSE CAPACITY: FACILITY TYPE: STATUS: 850 3 85 LICENSEE NAME{S): RANCHO HERITAGE SCHOOL Licensee has been advised that failure to complete the above agreed upon actions by the dates will result in this Department taking the following action(s): 1 • The facility will receive increased unannounced visits from Licensing for the next 24 months. This is 2 not to be considered probation, either formal or informal. The Department may at its discretion review this case with its legal consultant for possible administrative action. ! ~ In the event that legal action is taken, nothing in this plan precludes the Department from including the 7 above issues. 8 9 Effective January 1, 2007 the licensee must comply with AB 633 as follows: 10 Upon receipt by the licensee, the licensee is to provide to parents/guardians the following: 11 Copies of any licensing report that documents a Type A citation- this includes facility visits and 2 substantiated complaint investigations. Copies of any licensing documents pertaining to a noncompliance conference between licensing 1 15 management and licensees. 16 Copies of a summary of an accusation indicating the Department's intent to revoke the facility's 171icense. 18 Copies of any of the above licensing documents the licensee has received in the prior 12 montihs shall 19 be provided to parents/guardians of newly enrolling children. 20 The licensee shall keep verification of receipt in each child's file at the facility. 21 22 23 24 25 26 27 28 29 30 i! 0 A detailed letter regarding this conference will be mailed to the licensee within 5 calendar days. LICENSEE SIGNATURE DATE: 07/10/2012 MANAGER SIGNATURE: DATE: 07/10/2012 LIC9111 (FAS) • (12199}- (PUBLIC) Page: 3 of 4 ~ CDSS - STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF SOCIAL SERVICES VOLL UGH\1l0URNE DIRECTOR 3737 MAIN ST., SUITE 700 RIVERSIDE, CA 92501 EDMUND G. BROWN JR. GO'I/ERNOR July 06, 2012 -----I'!RA>-tmlf\JCJ=IO HERITAGE SCHOOL- 364809858 9488 19TH STREET RANCHO CUCAMONGA, CA 91701 FILE COPY Dear Mr. Hal Hazegh and Mrs. Mastaneh Hazegh: Verification was not received to support that the following deficiency cited on Licensing Report dated 6/20/2012 has been corrected: Section 101163(a) False Claims Please return a copy of this letter along with evidence of correction no later than 7/11/2012. Failure to provide adequate proof of correction by this date may result in another visit or further action as required by regulation. Thank you in advance for your cooperation. If you have any questions, please feel free to contact Kim Leung, Licensing Program Analyst at (951) 529-4713. Sincerely, KIM LEUNG Licensing Program Analy Inland Empire Child Care []jJ - coss \',~ll STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF SOCIAL SERVICES UGHTBOURNE OIR£C1CR 3737 MAIN ST., SUITE 700 RIVERSIDE, CA 92501 EDMUND G. BROWN JR. GOVERNOR June21,2012 RANCHO HERITAGE SCHOOL- 364809858 9488 19TH STREET RANCHO CUCMONGA. CA 91701 FILE COPY Dear Mr. Hal Hazegh and Mrs. Mastaneh Hazegh: This letter is to advise you that a Non-Compliance Conference has been scheduled for Tuesday, July 10, 2010 at 9:00 a.m. in the Inland Empire Child Care Office with Reynauldo Pennywell, Regional Manager, Marianne Donley, Licensing Program Manager and Kim Leung, Licensing Program Analyst. Your attendance at this conference is required. You may bring someone with you to participate in this conference (e.g. another provider, provider association representative, etc.). The conference will focus on the following issues: Care and Supervision Reporting Requirements Children's Personal Rights It is requested that you notify our office if date and/or time of conference require rescheduling. Also if you plan to bring someone with you to this conference please advise us as soon as possible. Please note that children are not allowed at this conference. Sincerely, REYNAULDO P Regional Manager Inland Empire Child Care STATE OF CAliFORNIA- HEAl.TH AND HUMAN SERVICES AGt:~.CY f\LE COPl CALJFORNIA DEPARTMENT OF SOCIAl. SERVICES NOTICE OF CIVIL PENALTIES DUE 0 i;i'i Initial Invoice INVOICE NO. Final Notice DISTRICT OR COUNTY OFFICE NUMBER 09/ H309 0902927 I IRancho Hentage School FISCAL YEAR FACILITY NAt-AE I2011/2012 FACILITY ADDRESS FACILITY TYPE \9488 19th Street STATE jCITY CA \ Rancho Cucamonga ZIP CODE I ! 850 OATE UC 422 SENT I07/06/2012 IPENALTY PCA COOE !84035 91701 rACIUTY NUMBER 364809858 !UCENSEE{S) OR UNLICENSED FACILITY OPERATOR i Rancho Heritage School !ADDRESS : 9488 19th Street ICITY ZIP COOIO: STATE · Rancho Cucamonga CA 91701 i I TITLE I Licensing Program Man The California Health and Safety Code, Sections 1548, 1568.0822, 1569.49, 1596.99, and 1597.62 provides for the imposition of civil penalties against any facility which fails to take corrective action within prescribed time periods. The California Health and Safety Code, Sections 1547, 1568.0821, 1569.485, 1596.89, 1596.891 and 1597.61 provides for the imposition of civil penalties against any unlicensed facility which fails to take corrective action within prescribed time periods. The California Health and Safety Code, Sections 1522, 1568.09, 1569.17, 1596.871, and 1596.8712 provides for the imposition of immediate civil penalties against any facility which fails to comply with fingerprinting or other criminal background requirements. Your facility has been found in violation of Community Care Licensing statutes and regulations. Failure to correct the deficiency(ies) cited on the Licensing Report (LIC 809 or LIC 9099) dated_6_12_0_i2_0_1_2_ _ _ _ __ has resulted in the following civil penalty assessment of: Penalty Amount Due ..................................... ---------------'SS=O:.:Oc:.:.0:::-0 Less Payment(s) Received ................................ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _____:::S.::O:.:.Oc:.O BALANCE DUE ......................................... --------------"'-$6=-:0:.::0:.:::.0c:.O Send the enclosed copy of this notice and your payment to the address shown below within 10 days. MAKE CHECKS PAYABLE TO THE CALIFORNIA DEPARTMENT OF SOCIAL SERVICES. Please write your invoice and facility number(s) on your check. Department of Social Services Community Care Licensing 3737 Main Street, Suite 700 Riverside, CA 92501 FAILURE TO PAY CIVIL PENALTY MAY RESULT IN ANY OR ALL OF THE FOLLOWING: • SMALL CLAIMS COURT ACTION • LICENSE DENIAL, SUSPENSION, OR REVOCATION • SEIZURE OF PERSONAL INCOME TAX REFUNDS LIC 422 (3/02) (PUBLIC) STATE OF CALIFORNIA- HEALTH AND HUr........ ~ SERVICES AGENCY CAL1rORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office 3737 MAIN ST., SUITE 700 RIVERSIDE, CA 92501 0612012012 RANCHO HERITAGE SCHOOL 364809858 9488 19TH STREET RANCHO CUCAMONGA. CA 91701 Dei""""""'""'' Citations Cleared Letter af Dear Licensee. The following cieOCiencies, initially cited during a visit on 00120.2!l"t2 have been deared: Plan of Com:c:tiotL Clearance Date: Ucensee ~ ::r:::z::l et 'S!:Ztff!I trnining during visit. Ucensee stated that the ~ l:an:1g -..:as provided on 6/14/2012 and 06/20/2012 6/1512012. Plan of Couec::tN::wc Clearance Date: 06/20/2012 LICENSIMG EVALUATOR NAME: Kim Leung TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: DATE: 06/2012012 This report must be available at Child Care and Group Home facirrties for public review for 3 years. Cleared POC Letter (FAS)- (04105) Page: 1 of 2 STATE OF CALIFORNIA- HEALTH AND HU~> ..• ,i SERVICES AGENCY CAt..u·ORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office 3737 MAIN ST., SUITE 700 RIVERSIDE, CA 92501 06/20/2012 RANCHO HERITAGE SCHOOL 364809858 COMMa!TS Please be adviSed of !he following requirement per Califoma ~ & Safely Code: e Per Section 15961!595(b) the licensee shall post the~ o!'Jeii C'!f Clta!ioos Cleared" verifying the licensee's comp!iance or noncompliance with the department's arner (UC809D or LIC 90990) to correct a type A deficiency that s subject to posting for a period of 3IJ ~ The "Letter of Deficiency Citations Cleared" shall be posted immediately upon receipt, immediately adjacent to, tl1e irll:erior side of the main door into the faciity and shal be posted for a period of 30 consecutive~ Failure to c:ompiy shall result in an immediate civil penalty of ooe tuaed dollars ($100). LICENSING EVALUATOR NAME: Kim Leung TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: 7 DATE: 06/20/2012 This report must be avallable at Child Care and Group Home I& Xos for public review for 3 years. Cleared POC Leltet'(FAS)- (0611)4) Page: 2 of 2 ' STATE OF CALIFORNIA- HEALTH AND HlJh .. •• ~ SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSJNG DIVISION CCLD Regional Office 3737 MAIN ST., SUITE 700 RIVERSIDE, CA 92501 06/20/2012 RANCHO HERITAGE SCHOOL 364809858 948819TH STREET RANCHO CUCAMONGA, CA 91701 Letter of D F i+q Citations Cleared Dear Ucensee. The following cleiiciencies, initially cited during a visit on O!li2'"uQ!J<2.. te1e been cleared: Plan of Ccrn:!dic:m: Clearance Date: Licensee~ ;r:d :t st:aftraining 06/20/2012 during visil licensee stated that !he s!a!lf~was provided on 6/1412012 and 6/1512012. LICENSING EVALUATOR NAME: Kim Leung TELEPHONE: (951) 529-4713 LICENsmG EVALUATOR SIGNATURE: DATE: 06/20/2012 This report must be available at Child Care and Group Home faciTmes for public review for 3 years. Cleared POC letter (FAS)- (04105) Page: 1 of 2 STATE OF CALIFORNIA -HEALTH AND HU.. _ .. ~SERVICES AGENCY CAUFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office 3737 MAIN ST., SUITE 700 RIVERSIDE, CA 92501 06/20/2012 RANCHO HERITAGE SCHOOL 364809858 COMME!flS Please be aa--J!Sed of !he following requirement per Calm, lid ~ & Safety Code: Per Sedioo ~59E..!l595ib) the licensee shall post the~ :lf~:ieily' Citations Cleared" verifying the licensee's mo~pliacy Citations Cleared Dear Lice iZ & The foiowing This report must be available at Child Care and Group Home facilities for public review for 3 years. Cleared POC Letter (FAS)- (04105) Page: 1 of 1 STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES A~ ..X CALIFORNIA DEPARTMENT OF SOCIAL SERVICES CIVIL PENALTY LEDGER PAYMENT, REDUCTION, OR WAIVER RECORD DISTRICT OFFICE NUMBER 09/ H309 INVOICE NO. __ o9_o_29_2_7- - - - - - - - ! I 201112012 IFACILITY NMAE Rancho Heritage School FACILITY ADDRESS 9488 19th Street FISCAL YEAR DATE LIC 422 SENT j FACILITY TYPE FACILITY PCA CODE 07/06/2012 84035 1850 IciTY I Rancho Cucamonga STATE CA ZIPCOOEi I 91701 LICENSEE{S) \FACILITY NUMBER Rancho Heritage School I 364809858 ADDRESS 9488 19th Street CITY ZIP CODE STATE Rancho Cucamonga CA ·--- 91701 I DATE AMOUNT _:=( CUMULATIVE BALANCE $6oo.oo 06/20/2012 1 I I ' Original Invoice Amount $600.00 I I 'Civil Penalty Waiver I Penalty Review Reduction ! !Penalty Review Reduction I Payment 1 - I l I '' !Payment 2 ' -- I I I Payment 3 I I Payment 4 I Payment 5 I BALANCE $600.00 - ·coMMENTS: I I_ LIC 422A (5101) 1 $600.00 CY STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICE( CALIFORNIA DEPARTMENT OF SOCIAL SERVICES CIVIL PENALTY ASSESSMENT --IMMEDIATE $150 FACIUlY NAME DATE Rancho Heritage School 06/20/2012 ZIP CODE FACILITY ADDRESS CnY STATE I 9488 19th Street Rancho Cucamonga CA ,91701 FACIUlY II: LlCENSEE(S) 364809858 Rancho Heritage School ----- A Licensing Report {LIC 809 or LIC 9099) was issued on .::0:.:6:.:12:.:0:.:/2:.:0-'=12=::::---- giving notice that your facility has been found in DATE violation of one or more requirements lor which an immediate civil penalty is warranted in accordance with one or more of the following California Health and Safety Code Sections: 1548, 1568.0822, 1569.49, 1596.99 and 1597.58. You are hereby notified that an immediate civil penalty of $150 per violation followed by $150 per day per violation until corrected is assessed tor the period of 06/20/2012 through 06/20/2012 lor the following violations: DATE DATE D Violations which result in injury, sickness or death of a client in care. (Does not apply to Residential Care Facilities lor the Chronically Ill or Foster Family Homes.) D Fire clearance violations (Does not apply to Family Child Care Homes.) Gli Absence of supervision D Accessible bodies of water D Accessible firearms, ammunition, or both D Licensing agent refused entry to a facility or any part of a facility D The presence of an excluded person on the premises Total #of (Per Day ) Violations: X$150 $ 150.00 Total Penalty Assessed YOU WILL RECEIVE AN INVOICE IN THE MAIL. DO NOT SEND MONEY UNTIL YOU RECEIVE YOUR INVOICE DATE NG PROGRAM ANALYST NAME OF LICENSING PROGRAM ANALYST ' Kim Leung NAME OF FACILITY REPRESENTATIVEITJTLE 06/20/2012 DATE 06/20/2012 Hal Hazegh, Licensee ,TITLE DATE I LIC421C {7/11) PAGE 1 OF2 STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGEN CALIFORNIA DEPARTMENT OF SOCIAL SERVICES CIVIL PENALTY ASSESSMENT FACIUTY NAME DATE Rancho Heritage School 06/20/2012 'FACILITY ADDRESS 9488 19th Street Cl~ ZiP CODE ~R;;ia~ni'!ch;;;.oO?._~;;;:u..,ca,-monga, CA 91701_ UCENSEE(S)/OPERATOA Rancho Heritage School 364809858 LICENSED FACILITY Civil penalties can be assessed against any facility which fails to take corrective action within prescribed time periods, per California Health and Safety Code Sections 1548, 1568.0822, 1569.49, 1596.99, and 1597.58. You are hereby notified that a civil penalty has been assessed. The above facility has been found in violation of the California Code of Regulations. Title 22, Divisions 6, and/or 12. Section(s) 101229(1)(a) 101223(a)(2) 101212(d) and/or California Health and Safety Code, Division 2. Chapters 3, 3.01, 3.2, 3.4, and 3.5, and 3.6. Section(s) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ A Licensing Report (LIC 809 or LIC 9099) was issued on _ _ _ _ _.J.D&91llffi"!1~12~Du1.J.1_ _ _ _ _ giving notice that failure to correct the above violation(s) would result in a civil penalty. DATE 0 Because you failed to make the corrections specified on the LIC 809, a civil penalty of $.______ is assessed for the period from through _ _ _ _ _ __ 0 Ill DATE DATE A civil penalty of $50 per violation per day, up to a maximum of $150 per violation per day will be assessed. This will continue until correction(s) is made to comply with the licensing laws, regulations. and approval of the California Department of Social Services or authorized licensing agency. Because you repeated a violation of the same subsection within a 12-month period, an immediate civil penalty of 450 oo is assessed for the period from 06/20/2012 through 0612012012 $ ~TE MTE 0 All Facility Types Except Child Care Centers: Second citation within a 12 month period; an immediate civil penalty of $150 per violation; then $50 per day per violation until corrections are made. Ill Child Care Centers Only: Second citation within a 12-month period; an immediate civil penalty of $150 per violation; then $150 per day per violation until corrections are made. ·0 Residential Care Facility for the Elderly (RCFE), Residential Care Facility for the Chronically Ill (RCF-CI): Third citation within a 12-month period; an immediate civil penalty of $1,000 per violation; then $100 per day per violation until corrections are made. 0 Family Child Care Home (FCCH). Child Care Center (CCC), Community Care Facility (CCF): Third citation within 12month period; an immediate civil penalty of $150 per violation; then $150 per day per violation until corrections are made. 0 FCCH and CCC only: Second or subsequent violation for failure to allow parent or guardian to enter and inspect facility or for retaliation/discrimination stemming from a request to enter or lodge a complaint. A civil penalty of $50 per violation. Total Penalty Assessed $.--'-'-45"'0"'.,_00::..__ _ _ __ YOU WILL RECEIVE AN INVOICE IN THE MAIL. DO NOT SEND MONEY UNTIL YOU RECEIVE YOUR INVOICE ' NAME OF FACILITY REPRESENTAllVE/TlTLE Kim Leung SIGNATURE OF LICENSING PROGRAI\1 ANALYST PAGE 1 OF2 Control Number 09-CC-20120614165059 STATE OF CAUFORNIA- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSfNG DIVISION COMPLAINT INVESTIGATION REPORT (Cont) CCLO Regional Office, 3737 MAIN ST., SUITE 700 RIVERSIDE, CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL DEFICIENCY INFORMATION FOR THIS PAGE: Deficiency Type POC Due Date I FACILITY NUMBER: 364809858 VISIT DATE: 06/20/2012 DEFICIENCIES PLAN OF CORRECTIONS(POCs) Section Number Type A 06/20/2012 Section Cited 101229(a)(1) 1 2 3 4 5 6 7 Care and Supervision. No child(ren) shall be left without the supervision, including visual observation, of a teacher at any time except as specified in sections 101216.2(e)(1) and 101230(c)(1). On 6/13/2012, child #1 was left alone on the playground for at least 8 minutes after 1 Licensee submitted proof of staff training during 2 visit. Licensee stated that the staff training was 3 provided on 6/14/2012 and 6/15/2012. 4 5 6 7 8 teacher escorted other children of the class back to 8 9 the activity room from the playground at 9 10 approximately 4:30pm. The child was found crying 10 11 11 on the playground, alone, by a passer-by. The 12 12 passer-by talked to the child through the fence, 13 entered the playground through one of the gates, 13 14 14 and brought the Type A 06/20/2012 Section Cited 101229(a)(1) 1 2 3 4 5 6 7 CONTINUATION child to the assistant director who was at the front office between 4:38pm and 4:40pm. Facilty was cited for the same violation on 91112011. Progressive civil penalty of $150 per day will be assessed. Zero tolerance civil 8 penalty of $150 per day will be assessed. Total 9 civil penalty assessedfor this date will be $300. 10 11 12 13 14 1 2 3 4 5 6 7 8 9 10 11 12 13 14 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: Marianne Donley TELEPHONE: (951) 782-4200 LICENSING EVALUATOR NAME: Kim Leu~g TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2012 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2012 This Notice must be posted for 30 days LIC9099 {FAS) -(06104) Page: 2 of2 Control Number 09-CC-20120614165059 STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DMSION COMPLAINT INVESTIGATION REPORT (Cont) CCLD Regional Office, 3737 MAIN ST., SUITE 700 RIVERSIDE, CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL DEFICIENCY INFORMATION FOR THIS PAGE: Deficiency Type POC Due Date I Section Number Type A 06/20/2012 Section Cited 101223(a)(2) FACILITY NUMBER: 364809858 VISIT DATE: 06/20/2012 DEFICIENCIES PLAN OF CORRECTIONS(POCs) 1 2 3 4 5 6 7 playground for at least 8 minutes. Staff members were unaware of the child's whereabout until a passer-by who found the 8 9 10 11 12 13 14 a child crying on the playground brought the child back to the front office. Facility failed to ensure the 9 child's safety while the child was receiving care at 10 the facility. Facility was cited for the same violation 11 on 911/2011. Progressive civil panalty of $150 par 12 day will be assessed. Total civil penalty assessed 13 14 for this date for this violation will be $150. 1 2 1 2 3 4 4 Personal Rights. Each child shall be accorded safe, heatthful and comfortable accommodations, furnishings and equipment. On 6/13/2012, child #1 was left alone on the 1 Licensee submitted proof of staff training during 2 visit. Licensee stated that the staff training was 3 provided on 6/14/2012 and 6/15/2012. 4 5 6 7 3 5 6 7 5 6 1 2 1 2 3 4 3 4 5 6 7 5 6 7 7 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: Marianne Donley TELEPHONE: (951) 782-4200 LICENSING EVALUATOR NAME: Kim Leung TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2012 I acknowledge receipt of this fonn and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2012 This Notice must be posted for 30 days LIC9099 (FAS} ·(06/04) Page: 2 of2 STATE OF CAUFORNIA ~HEALTH AND HUMAN SERVICES AGENCY CAUFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSING DMSION FACILITY EVALUATION REPORT (Cont) CCLD Regional Office, 3737 MAIN ST., SUITE 700 RWERSIDE, CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL DEFICIENCY INFORMATION FOR THIS PAGE: Deficiency Type POC Due Date I FACILITY NUMBER: 364809858 VISIT DATE: 06/19/2012 DEFICIENCIES PLAN OF CORRECTIONS(POCs) Section Number TypeB 06/20/2012 Section Cited 101212(d) 1 2 3 4 5 6 7 Reporting Requirements. A report shall be made to the Department within 24 hours of the occurrence of any unusual incident as specified. A child was left alone on the playground on 6/13/2012 after teacher escorted other children back indoor from the playground. The child was brought back to the office by a passer-by. 1 licensee will submit written Unusual Incident 2 Report to CCL. 3 4 5 6 7 8 9 10 11 12 13 14 licensee failed to report the incident to Community Care licensing. Facility was cited for the same deficiency on 9/1/2011. PROGRESSIVE CIVIL PENALTY OF $150 PER DAY WILL BE ASSESSED. 8 9 10 11 12 13 14 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 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: Marianne Donley TELEPHONE: (951) 782-4200 LICENSING EVALUATOR NAME: Kim Leung TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2012 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2012 LIC809 (FAS)- (06104) Page: 1 of 1 STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DMSION FACILITY EVALUATION REPORT CCLD Regional Offlce,3737 MAIN ST., SUITE700 RIVERSIDE, CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL ADMINISTRATOR:MASTANEH HAZEGH 9488 19TH STREET ADDRESS: CITY: RANCHO CUCAMONGA CAPACITY: 85 TYPE OF VISIT: Case Management • Deficiencies MET WITH: Hal Hazegh 1 2 3 4 5 6 7 8 9 10 11 STATE:CA CENSUS: 36 UNANNOUNCED FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 364809858 850 (909) 483-8250 91701 06/20/2012 11:29AM 02:00PM NARRATIVE LPA Kim Leung conducted complaint investigation at the facility. During the investigation process, it was disclosed that a child was left alone on the playground on 6/1312012 and was brought back to the office by a passer-by. Licensee stated that tl)e incident was not reported to Community Care Licensing. During the investigation process, LPA was provided with misleading infonnation in regards to how the child was brought back to the office. Licensee Hal Hazegh stated that misleading infonnation was also provided to him in the same manner by facility staff and therefore the same infonnation was provided to the child's parent. See LIC809D for deficiencies cited per California Code of Regulations Title 22 Regulations. An exit interview was held with the director. A Notice of Site visit was issued and must be posted for 30 days. A copy of this report was provided to the facility. Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. 12 13 14 15 16 17 This report shall be public record for three years. 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME: Marianne Donley TELEPHONE: (951) 782-4200 LICENSING EVALUATOR NAME: Kim Leung TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: DATE: 06/2012012 FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2012 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC809 (FAS)- (06104} Page: 1 of 1 STATE OF CALIFORNIA· HEALTH AND HlrM.nN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FACILITY EVALUATION REPORT(Cont) CCLD Regional Office, 3737 MAIN ST., SUITE 700 RIVERSIDE, CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL DEFICIENCY INFORMATION FOR THIS PAGE: FACILITY NUMBER: 364809858 VISIT DATE: 06/20/2012 Deficiency Type POC Due Date I DEFICIENCIES PLAN OF CORRECTIONS(POCs) Section Number Type A 06/21/2012 Section Cited 101163{a) 1 2 3 4 5 6 7 False Claims. No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the child care center or any of the services provided by the center. A child was left alone on the playground on 6/13/2012 and was brought back to the 8 office by a passer-by. During the investigation 9 process. LPA was provided with misleading 10 information in regards to how the child was brought 11 back to the office. Licensee Hal Hazegh stated 12 that misleading information was also provided to 13 him in the same manner by facility staff and 14 therefore the same information was provided to the child's parent. 1 Licensee will review the regulation, Section 101163 2 with all staff members and submit a written 3 statement with staff signatures by 6/21/2012. 4 5 6 7 8 9 10 11 12 13 14 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 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: Marianne Donley TELEPHONE: (951) 782-4200 LICENSING EVALUATOR NAME: Kim Leung TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2012 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2012 This Notice must be posted for 30 days l.ICS09 (FAS) • (06/04} Page: 3 of3 STATE OF CALIFORNIA· HEALTH AND HUI'n ...r-1 SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSING DIVISION FACILITY EVALUATION REPORT(Cont) CCLD Regional Office, 3737 MAIN ST., SUITE 700 RIVERSIDE, CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL DEFICIENCY INFORMATION FOR THIS PAGE: Deficiency Type POC Due Date J Section Number Type B 06/20/2012 Section Cited 101212(d) FACILITY NUMBER: 364809858 VISIT DATE: 06/2012012 DEFICIENCIES 1 Reporting Requirements. A report shall be made 2 to the Department within 24 hours of the 3 occurrence of any unusual incident as specified. PLAN OF CORRECTIONS(POCs) 1 Licensee will submit written Unusual Incident 2 Report to CCL. 3 4 A child was left alone on the playground on 4 5 6/13/2012 after teacher escorted other children 6 back indoor from the playground. The child was 7 brought back to the office by a passer-by. 5 6 7 8 9 10 11 12 13 14 10 11 12 13 14 Licensee failed to report the incident to Community 8 9 Care Licensing. Facility was cited for the same deficiency on 9/1/2011. PROGRESSIVE CIVIL PENALTY OF $150 PER DAY WILL BE ASSESSED. 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 1 2 3 4 4 5 6 7 5 6 7 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: Marianne Donley TELEPHONE: (951) 782-4200 LICENSING EVALUATOR NAME: Kim Leung TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2012 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 0612012012 UC809 (FAS)· (06/04) Page: 2 of3 STATE OF CALIFORNIA· HEALTH AND HUr..AN SERVICES AGENCY CAUFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION COMPLAINT INVESTIGATION REPORT CCLO Regional Office, 3737 MAIN ST., SUITE 700 RIVERSIDE, CA 92501 This is an official report of an unannounced visit/investigation of a complaint received in our office on 06/14/2012 and conducted by Evaluator Kim Leung PUBLIC COMPLAINT CONTROL NUMBER: 09-CC-20120614165059 FACILITY NAME: RANCHO HERITAGE SCHOOL ADMINISTRATOR: MASTANEH HAZEGH ADDRESS: 9488 19TH STREET CITY: RANCHO CUCAMONGA CAPACITY: 85 MET WITH: HaiHazegh FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: STATE: DATE: CENSUS: UNANNOUNCED TIME VISIT BEGAN: TIME COMPLETED: 364809858 850 (909) 483-8250 91701 06/20/2012 11:29AM 02:00PM ALLEGATION(S): 1 Lack of Supervision 2 3 4 Personal Rights Violation 5 6 7 8 9 INVESTIGATION FINDINGS: 1 LPA Kim Leung visited the facility conducting a complaint investigation this date. During visit, LPA reviewed 2 records and conducted interviews. It was disclosed ltlat on 6/13/2012, child #1 was left alone on the 3 playground for at least 8 minutes after teacher escorted other children of the class back to the activity room 4 from the playground at approximately 4:30pm. LPA obtained information that the child was found crying on the 5 playground, alone, by a passer-by. LPA obtained information that the passer-by talked to the child through the 6 fence and then entered the playground through one of the gates. It was disclosed that the child was brought to 7 the assistant director at the front office by the passer-by between 4:38pm and 4:40pm. Information gathered 8 support the allegations. This complaint is therefore substantiated. See LIC9099D for deficiencies cited per 9 California Code of Regulations Title 22 Regulations. 10 11 An exit interview was held with the director. A Notice of Site visit was issued and must be posted for 30 days. 12 A copy of this report was provided to the facility. Upon receipt, licensee shall post and provide copies of this 13 licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility durin the next 12 months. This report shall be public record for three years. Substantiated SUPERVISOR'S NAME: Marianne Donley Estimated Days of Completion: TELEPHONE: (951) 782-4200 LICENSING EVALUATOR NAME: Kim Leung TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2012 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2012 This report must be available at Child Care and Group Home facilities for public review for 3 years. LIC9099 (FAS)- (06104) Page: 1 of 3 Control Number 09-CC-20120514165059 STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION COMPLAINT INVESTIGATION REPORT (Cont) CCLD Regional Office, 3737 MAIN ST., SUITE 700 RIVERSIDE, CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL DEFICIENCY INFORMATION FOR THIS PAGE: FACILITY NUMBER: 364809858 VISIT DATE: 05/20/2012 Deficiency Type POC Due Date I PLAN OF CORRECTIONS(POCs) DEFICIENCIES Section Number Type A 06/20/2012 Section Cited 101229(a)(1) Type A 06/20/2012 Section Cited 101229(a)(1) 5 101230(c)(1). 6 On 6/13/2012, child #1 was left alone on the 1 Licensee submitted proof of staff training during 2 visil Licensee stated that the staff training was 3 provided on 611412012 and 6/15/2012. 4 5 6 7 playground for at least 8 minutes after 7 8 9 10 11 12 13 14 teacher escorted other children of the class back to the activity room from the playground at approximately 4:30pm. The child was found crying on the playground, alone, by a passer-by. The passer-by talked to the child through the fence, entered the playground through one of the gates, 8 9 10 11 12 13 14 1 2 3 4 5 6 CONTINUATION 1 Care and Supervision. No child(ren) shall be left 2 without the supervision, including visual 3 observation, of a teacher at any time except as 4 specified in sections 101216.2(e}{1) and and brought the child to the assistant director who was at the front office between 4:38pm and 4:40pm. Facilty was cited for the same violation on 911/2011. Progressive civil penalty of $150 per day will be 7 assessed. Zero tolerance civil 8 penalty of $150 per day will be assessed. Total 9 civil penalty assessedfor this date will be $300. 10 11 12 13 14 1 2 3 4 5 6 7 8 9 10 11 12 13 14 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: Marianne Donley TELEPHONE: (951) 782-4200 LICENSING EVALUATOR NAME: Kim Leung TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: DATE: 0612012012 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2012 This Notice must be posted for 30 days LIC9099 (FAS)- (OG/04) Page: 2 of3 t llf COPY STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENo.... CALIFORNIA DEPARTMENT OF SOCIAL SERVICES NOTICE OF CIVIL PENALTIES DUE 0 INVOICE NO. 0 Initial Invoice Final Notice DISTRICT OR COUNTY OFFICE NUMBER 09/ H108 0902927 IFISCAL YEAR FACJLm' NAME Rancho Heritage School 2011/2012 FACILITY TYPE FACILITY ADDRESS 9488 19th Street 850 STATE CITY 7/15/2013 PENALTY PCA CODE 84035 ZIPCOOE CA Rancho Cucamonga DATE UC 422 SENT 91701 I FACILm' NUMBER 364809858 UCENSEE(S) OR UNUCENSED FACIUTY OPERATOR Rancho Heritage School ADDRESS DATE 7/15/2013 9488 19th Street CITY STATE Rancho Cucamonga CA ZIP CODE 91701 Licensing Program Manager I The California Health and Safety Code, Sections 1548, 1568.0822, 1569.49, 1596.99, and 1597.62 provides for the imposition of civil penalties against any facility which fails to take corrective action within prescribed time periods. The California Health and Safety Code, Sections 1547, 1568.0821, 1569.485, 1596.89, 1596.891 and 1597.61 provides for the imposition of civil penalties against any unlicensed facility which fails to take corrective action within prescribed time periods. The California Health and Safety Code, Sections 1522, 1568.09, 1569.17, 1596.871, and 1596.8712 provides for the imposition of immediate civil penalties against any facility which fails to comply with fingerprinting or other criminal background requirements. Your facility has been found in violation of Community Care Licensing statutes and regulations. Failure to correct the deficiency(ies) cited on the Licensing Report (LIC 809 or LIC 9099) dated._S_/_2_01_2_0_12_ _ _ _ _ __ has resulted in the following civil penalty assessment of: Penalty Amount Due ..................................... _ _ _ _ _ _ _ _ _ _ _ _ _ _$:.::6::.o0o..::O::.:.O"'-O Less Payment(s) Received ................................ _ _ _ _ _ _ _ _ _ _ _ _ _ _,.,_$1_,_,5::.o0:.::.0"'-0 BALANCE DUE .. ....................................... _ _ _ _ _ _ _ _ _ _ _ _ __:$<.::0::.:.0'-"0 Send the enclosed copy of this notice and your payment to the address shown below within 10 days. MAKE CHECKS PAYABLE TO THE CALIFORNIA DEPARTMENT OF SOCIAL SERVICES. Please write your invoice and facility number(s) on your check. Department of Social Services Community Care Licensing 3737 Main Street, ?uile _700 Riverside, CA 92501 FAILURE TO PAY CIVIL PENALTY MAY RESULT IN ANY OR ALL OF THE FOLLOWING: • SMALL CLAIMS COURT ACTION • LICENSE DENIAL, SUSPENSION, OR REVOCATION • SEIZURE OF PERSONAL INCOME TAX REFUNDS UC 422 {3/02) (PUBLIC) STATE OF CALIFORNIA -HEALTH AND HUMAN SERVICES AG. CALIFORNIA DEPARTMENT OF SOCIAL SERVICES CIVIL PENALTY LEDGER PAYMENT, REDUCTION, OR WAIVER RECORD INVOICE NO._ _::_og::..:o=-:29:.::2.:_7- - - - - - - - DISTRICT OFFICE NUMBER 09/ H108 FISCAL YEAR FACILITY NAME Rancho Heritage School DATE LIC 422 SENT 2011/2012 FACILITY ADDRESS 9488 19th Street Rancho Cucamonga 84035 850 ZIP CODE STATE CITY CA 07/15/2013 FACILITY PCA CODE FACILITY TYPE 91701 IF;~;;;;~~ UCENSEE{S} Rancho Heritage School I ADDRESS 9488 19th Street STATE CITY Rancho Cucamonga CA ZlPCODE 91701 DATE AMOUNT CUMULATIVE BALANCE Original Invoice Amount 06/20/2012 $600.00 $600.00 11/02/2012 $300.00 $300.00 2/27/2013 $150.00 $150.00 7/12/2013 $150.00 $0.00 Civil Penalty Waiver Penalty Review Reduction Penalty Review Reduction Payment 1 Payment 2 Payment 3 Payment4 Payment 5 ' BALANCE $0.00 COMMENTS: 11/2/2012 mo # 2/27/2013 mo # 7/12/2013 mo # UC 422A (5101) =0086754133 =0039316620 =0091247845 $0.00 STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICE COMMUNITY CARE LICENSING DIVISION CASH STATE RECEIPT FOR FEE TYPE PAID: CIVIL PENALlY THESE FEES ARE NON-REFUNDABLE FACILITY NUMBER REMITTER PCA PAY TYPE DATE OF CHECK CHECK NUMBER TOTAL AMOUNT COLLECTED 364809858 Rancho Harnage School 84035 Money Order 07/12/2013 0091247845 $150.00 RECEIPT NO: DATE ISSUED: OFFICE: R09-000262599 07/15/2013 09 STATE OF CAUFORNIA ·HEALTH AND HUMAN SERVICES AGENCY FACILITY EVALUATION REPORT FACILITY NAME: RANCHO HERITAGE SCHOOL ADMINISTRATOR:MASTANEH HAZEGH ADDRESS: 948819TH STREET CITY: RANCHO CUCAMONGA CAPACITY: 85 TYPE OF VISIT: Case Management MET WITH: Hal Hazegh 1 2 3 4 5 6 7 8 9 CAUFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSING DMSlON CCLD Regional Office, 3737 MAIN ST., SUITE 700 RIVERSIDE, CA 92501 FACILITY NUMBER: FACILITY TYPE: TELEPHONE: STATE:CA ZIP CODE: CENSUS:29 DATE: UNANNOUNCED TIME BEGAN: TIME COMPLETED: 364809858 850 (909) 483-8250 91701 12/14/2012 !1:30AM 02:45PM NARRATIVE LPA Kim Leung arrived at the facility conducting an annual evaluation. During visit, licensee Hal Hazegh submitted an unusual incident report. The report was reviewed with Mr. Hazegh and records were reviewed. Interviews with staff were conducted. Based on the information obtained during the visit, there appeared to be no violations of Title 22 Regulations pertaining to the reported incident. An exit interview was held with Mr. Hal Hazegh. A copy of this report was provided to the licensee 10 on this date. 11 12 A Notice of Site visit was issued, along with a copy of this report. This report shall be public record 13 for three years. 14 15 16 17 18 19 20 21 22 23 24 25 SUPERVISOR'S NAME: Marianne Donley TELEPHONE: (951) 782-4200 LICENSING EVALUATOR NAME: Kim Leung TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: r::-..-.::;..."-·~) DATE: 12/14/2012 I acknowledge receipt of this fonm and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2012 This report must be available at Child Care and Group Home facilities for public review for 3 years. UC809 (FAS) • {06104) Page: 1 of 1 STATE OF CALIFORNiA~ HEALTH AND HUMAN SERVICES AGENCY CAUFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FACILITY EVALUATION REPORT CCLD Regional Office, 3737 MAJN ST., SUITE 700 RIVERSIDE, CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL HAZEGH ADDRESS: 9488 19TH STREET CITY: RANCHO CUCAMONGA CAPACITY: 85 TYPE OF VISIT: Annual/Required Hal Hazegh MET WITH: ADMINI~TRATOR:MASTANEH STATE:CA CENSUS: 29 UNANNOUNCED FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED: 364809858 850 (909) 483-8250 91701 12/14/2012 11:30 AM 02:35PM NARRATIVE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Licensing Program Analyst (LPA), Kim Leung conducted a comprehensive annual visit. A review of a sampling of the staff records and children's records were conducted as part of this evaluation. See Children's Records Review (LIC857) and Staff Records Review (LIC859). Most recent fire drill was conducted on 11/17/2012 and earthquake drill was conducted on 11/14/2012 per drill log. Medication forms were reviewed for the medications stored on site. • The licensee is asked to update the following documents, if applicable, and submit to licensing within 30 days: 1.LIC 500 Personnel Report 2.LIC 610 Emergency & Disaster Plan 3.Parent Handbook/ Program Curriculum/Admission policies and procedures/ fee schedule (only if changes have been made) 4.LIC 309 Administrative Organization (only if changes have been made) • The following items have been posted and are updated where necessary: - License Emergency Disaster Plan (LIC61 0) - Parenfs Rights Poster (PUB393) - Personal Rights (LIC613A) - Child Car Seat Law - Breakfast, Snack and Lunch Menu • The licensee has been informed that all employees must be associated to the facility. If the licensee fails to have proof of a fingerprint clearance or fails to associate a previously cleared individual to the facility, a civil penalty of $100.00, per day the person has been present, will be assessed. The first violation is subject to the penalty for up to five days. If there is a subsequent violation in a 12 month period, the fine will continue for up to 30 days. SUPERVISOR'S NAME: Marianne Donley TELEPHONE: (951) 782-4200 LICENSING EVALUATOR NAME: Kim Leung TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2012 I acknowledge receipt of this fonn and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2012 This report must be available at Child Care and Group Home facilities for public review for 3 years. UCB09 (FAS) ~ (06104) Page: 1 of 1 STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSING DMSION FACILITY EVALUATION REPORT (Cont) CCLD Regional Office, 3737 MAIN ST., SUITE 700 RIVERSIDE, CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL FACILITY NUMBER: 364809858 VISIT DATE: 12114/2012 NARRATIVE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 • A review of staff records on 12/14/2012 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. • The facility representative was advised that the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days. If a serious violation is cited, a copy of the licensing report (LIC809 or LIC9099) must also be posted for 30 days. If these requirements are not met, civil penalties in the amount of $100 per violation will be assessed. • AB 978- Zero Tolerance Related Regulations went into effect January 18, 2011 -In accordance with California Health and Safety Code Section 1596.99(c)/1597.58(c)- it was explained that an immediate $150 Civil penalty will be assessed for each serious violation and a civil penalty of $150 per day per violation will be assessed until corrected. See LIC809D for cited deficiencies in accordance with the California Code of Regulations Title 22, Division 12. An exit interview was conducted, appeal rights discussed, Notice of Site Visit was posted and must stay posted for 30 days. A copy of this report was provided. A copy of this report must be made available to the public, at the facility site, for 3 years. 23 24 25 26 27 28 29 30 31 32 SUPERVISOR'S NAME: Marianne Donley TELEPHONE: (951) 782-4200 LICENSING EVALUATOR NAME: Kim Leung TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: \. DATE: 1211412012 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: ~ LICB09 (FAS)· (06104) DATE: 12114/2012 Page: 1 of 1 STATEOFCAUFORNIA ·HEALTH AND HUMAN SERVICES AGENCY CAUFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSING OIVISJON FACILITY EVALUATION REPORT (Cont) CCLD Regional Office, 3737 MAIN ST., SUITE 700 RIVERSIDE, CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL DEFICIENCY INFORMATION FOR THIS PAGE: Deficiency Type POC Due Date I Section Number Type B 12/17/2012 Section Cited 101239(n) TypeB 12/17/2012 Section Cited 101239(n) FACILITY NUMBER: 364809858 VISIT DATE: 12/14/2012 DEFICIENCIES PLAN OF CORRECTIONS(POCs) 1 Fixtures, Furniture, Equipment and Supplies. 1 Ucensee will make repair and submit written 2 Furniture and equipment shall be in good condition, 2 statement to CCL by 12/17/2012 as evidence of 3 free of sharp, loose, or pointed parts. The drinking 3 correction after repair has been completed. 4 fountain on the playground is not draining. 5 6 7 4 5 6 7 1 Fixtures, Furniture, Equipment and Supplies. 1 Licensee will re-attach the parts and submit written 2 Furniture and equipment shall be in good condition, 2 statement and pictures to CCL by 12/17/2012 as 3 free of sharp, loose, or pointed parts. One of the 3 proof of correction. 4 four walls of the playhouse on the south side of the 5 playground is detached from the other part of the 6 house. 7 4 5 6 7 1 2 3 1 2 3 4 5 6 4 5 6 7 7 1 2 3 1 2 3 4 5 6 4 5 6 7 7 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: Marianne Donley TELEPHONE: (951) 782-4200 LICENSING EVALUATOR NAME: Kim Leung TELEPHONE: (951} 529-4713 LICENSING EVALUATOR SIGNATURE: ; . - DATE: 12/14/2012 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2012 UC809 (FAS)-(06104) Page: 1 of 1 FILE COPY STATE OF CAUFORNJA- HEALTH AND HUMAN SERVICES AG CALIFORNIA DEPARTMENT OF SOCIAL SERVICES NOTICE OF CIVIL PENALTIES DUE Q1 Final Notice Initial Invoice INVOICE NO. DISTRICT OR COUNTY OFFICE NUMBER 09/ H309 0902927 J FACILITY NAME FISCAL YEAR I Rancho Heritage School 2011/2012 i FACILITY TYPE FACILITY ADDRESS 9488 19th Street 850 c•TY STATE Rancho Cucamonga CA DATE UC 422 SENT 2/27/2013 IPENALTY PCA CODE j84035 ZIP CODE: 91701 l FACILITY NUMBER I 364809858 CiC-f:NsEE{S) OR UNLICENSED FACILITY OPERATOR · Rancho Heritage School ~ADDReSS __I i SUPERVISOR APPROVAL I DATE 2/27/2013 19488 19th Street c•TY STATE I Rancho Cucamonga__ CA i TITLE i_l:icensj~9, Program Manager I The California Health and Safety Code, Sections 1548, 1568.0822, 1569.49, 1596.99, and 1597.62 provides for the imposition of civil penalties against any facility which fails to take corrective action within prescribed time periods. Tile California Health and Safety Code, Sections 1547, 1568.0821, 1569.485, 1596.89, 1596.891 and 1597.61 provides for the imposition of civil penalties against any unlicensed facility which fails to take corrective action within prescribed time periods. The California Health and Safety Code, Sections 1522, 1568.09, 1569.17, 1596.871, and 1596.8712 provides for the imposition of immediate civil penalties against any facility which fails to comply with fingerprinting or other criminal background requirements. Your facility has been found in violation of Community Care Licensing statutes and regulations. Failure to correct the deficiency(ies) cited on the Licensing Report (LIC 809 or LIC 9099) dated,_6_1_20_1_2_0_12_ _ _ _ _ __ has resulted in the following civil penalty assessment of: Penalty Amount Due ..................................... _ _ _ _ _ _ _ _ _ _ _ _ _ _.:::$:::.60:::0:::..0=0 Less Payment(s) Received ................................ ----------------'-$4"'5"'0"'.0-'-'-0 BALANCE DUE ......................................... --------------'$"-1'-"5"'0'-".0"-0 Send the enclosed copy of this notice and your payment to the address shown below within 10 days. MAKE CHECKS PAYABLE TO THE CALIFORNIA DEPARTMENT OF SOCIAL SERVICES. Please write your invoice and facility number(s) on your check. Department of Social Services Community Care Licensing 3737 Main Street. Suite 700 Riverside, CA 92501 FAILURE TO PAY CIVIL PENALTY MAY RESULT IN ANY OR ALL OF THE FOLLOWING: • SMALL CLAIMS COURT ACTION • LICENSE DENIAL, SUSPENSION, OR REVOCATION • SEIZURE OF PERSONAL INCOME TAX REFUNDS L!C 422 (:!102) (PUBLIC) STAT€ OF CALIFORNIA- HEALTH AND liUMAN SERVICES A, CALIFORNIA DEPARTMENT OF SOCIAL SERVICES CIVIL PENALTY LEDGER PAYMENT, REDUCTION, OR WAIVER RECORD INVOICE N0. _ _:0.::90:.::2.::92:.:..7_ _ _ _ _ _ _ __ DISTRICT OFFICE NUMBER 09/ H309 j FACILITY NAME i FISCAL YEAR ' Rancho Heritage School DATE LIC 422 SENT 0212712013 1201112012 I i FACILITY ADDRESS I FACILITY PCA CODE FACILITY TYPE i 9488 19th Street ~ ~~·~~~-----------jCITY STATE I Rancho Cucamonga CA , _____,I' I ~0~3~5~----------~ 850 ZIP CODE! 91701 J jFACILITY NUMBER IUCENSEE(S) Rancho Heritage Scho~o~l_ _ _ _ __ j364809858 ADDRESS C>TY STATE LRaf1cho Cucamonga --- --------· CA -- 1- - -- !Original Invoice Amount ~ --- !Penalty Review Reduction I~------·---------------· Penalty Review Reduction -- - ' I '' I Payment 3 - -· - ' - I -- ----------- ----·--··--- - ----------' ----! I 1 ''' ------- - · - - - - ----~- -- -----· -$300.00 ·-- $300.00 --- $150.00 ' --·$150.00 I I I I ' $600-00 ---- ·--·- Ii 2/27/2013 !Payment 4 Payment 5 --·-- I ' 11/0212012 \ ! ! -- I -·-- ----- --------- $600-00 ' ' CUMULATIVI; BALANCE ' I -· ---1--~----~i ! --- I AMOUNT I I ! I )Payment 2 I I - ... --··-·· -·- I - DATI;_ i ~~ivi~ PenaltyWaiver- ------. -· !Payment 1 : i 0612012012 ------------------- - - - I 91701 I - -· I I I !BALANCE COMMENTS: LIC422A{!>-'01) $150.00 1 $150.00 STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICE COMMUNITY CARE LICENSING DIVISION CASH STATE RECEIPT FOR FEE TYPE PAID: CIVIL PENALTV THESE FEES ARE NON-REFUNDABLE FACILITY NUMBER REMITIER PCA PAY TYPE DATE OF CHECK CHECK NUMBER TOTAL AMOUNT COLLECTED 364809858 Rancho Heritage School 84035 Check 02127/2013 0039316620 $150.00 RECEIPT NO: DATE ISSUED: OFFICE: R09-000251321 02/27/2013 09 STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FACILITY EVALUATION REPORT CCLO Regional Office, 3737 MAIN ST., SUITE 700 RIVERSIDE, CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL ADMINISTRATOR:MASTANEH HAZEGH ADDRESS: 9488 19TH STREET CITY: RANCHO CUCAMONGA CAPACITY: 85 TYPE OF VISIT: Case Management - Incident MET WITH: Hal Hazegh 1 2 FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: STATE:CA CENSUS: 29 DATE: UNANNOUNCED TIME BEGAN: TIME COMPLETED: 364809858 850 (909) 483-8250 91701 12/14/2012 11:30AM 02:45PM NARRATIVE LPA Kim Leung arrived at the facility conducting an annual evaluation. During visit, licensee Hal Hazegh submitted an unusual incident report. The report was reviewed with Mr. Hazegh and records were reviewed. Interviews with staff were conducted. 3 4 5 Based on the information obtained during the visit, there appeared to be no violations of Title 22 6 Regulations pertaining to the reported incident. 7 8 An exit interview was held with Mr. Hal Hazegh. A copy of this report was provided to the licensee 9 10 on this date. 11 12 A Notice of Site visit was issued, along with a copy of this report. This report shall be public record 13 for three years. 14 15 16 17 18 19 20 21 22 23 24 25 TELEPHONE: (951) 782-4200 SUPERVISOR'S NAME: Marianne Donley LICENSING EVALUATOR NAME: Kim Leung TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2012 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2012 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 1 STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DlVISION FACILITY EVALUATION REPORT (Cont) CCLD Regional Office, 3737 MAIN ST., SUITE 700 RIVERSIDE, CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL FACILITY NUMBER: 364809858 VISIT DATE: 12/14/2012 NARRATIVE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 • A review of staff records on 12/14/2012 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. • The facility representative was advised that the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days. If a serious violation is cited, a copy of the licensing report (LIC809 or LIC9099) must also be posted for 30 days. If these requirements are not met, civil penalties in the amount of $100 per violation will be assessed. • AB 978- Zero Tolerance Related Regulations went into effect January 18, 2011 -In accordance with California Health and Safety Code Section 1596.99(c)/1597 .58( c) - it was explained that an immediate $150 Civil penalty will be assessed for each serious violation and a civil penalty of $150 per day per violation will be assessed until corrected. See LIC809D for cited deficiencies in accordance with the California Code of Regulations Title 22, Division 12. An exit interview was conducted, appeal rights discussed, Notice of Site Visit was posted and must stay posted for 30 days. A copy of this report was provided. A copy of this report must be made available to the public, at the facility site, for 3 years. 23 24 25 26 27 28 29 30 31 32 SUPERVISOR'S NAME: Marianne Donley TELEPHONE: (951) 782-4200 LICENSING EVALUATOR NAME: Kim Leung TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: \. ?-~~llll!r-:liilllllli:......,;_-.--, DATE: 12/14/2012 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: ~ LIC809 {FAS) • (06/04) DATE: 12114/2012 Page: 2 of 3 STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION FACILITY EVALUATION REPORT (Cont) CCLO Regional Office, 3737 MAIN ST., SUITE 700 RIVERSIDE, CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL DEFICIENCY INFORMATION FOR THIS PAGE: FACILITY NUMBER: 364809858 VISIT DATE: 1211412012 Deficiency Type POC Due Date I PLAN OF CORRECTIONS(POCs) DEFICIENCIES Section Number TypeS 1211712012 Section Cited 101239(n) Type B 1211712012 Section Cited 101239(n) 1 Licensee will make repair and submit written 1 Fixtures, Furniture, Equipment and Supplies. 2 Furniture and equipment shall be in good condition, 2 statement to CCL by 12/17/2012 as evidence of 3 free of sharp, loose, or pointed parts. The drinking 3 correction after repair has been completed. 4 fountain on the playground is not draining. 5 6 4 5 6 7 7 1 Licensee will re-attach the parts and submit written 1 Fixtures, Furniture, Equipment and Supplies. 2 Furniture and equipment shall be in good condition, 2 statement and pictures to CCL by 1211712012 as 3 free of sharp, loose, or pointed parts. One of the 3 proof of correction. 4 four walls of the playhouse on the south side of the 5 playground is detached from the other part of the 6 house. 7 4 5 6 7 1 2 3 1 2 3 4 5 6 7 4 5 6 7 1 2 3 1 2 3 4 5 6 7 4 5 6 7 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: Marianne Donley TELEPHONE: (951) 782-4200 LICENSING EVALUATOR NAME: Kim Leung TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: ; . - DATE: 1211412012 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 1211412012 LIC809 (FAS) -(06!04) Page: 3 of3 STATE OF C/IJ.IFORNIA- HEALTH AND HUMMI SERVICES NF NOTICE OF CIVIL PENALTIES DUE fllE COPl INVOICE NO. C/IJ.IFORtM DEPI\RTMENT OF SOCIAL SERVICES D Initial Invoice 0 Final Notice DISTRICT OR COUNTY OFFICE NUMBER 0902927 FACIUTY NAME FISCAL YEAR Rancho Heritage School 201112012 FACILITY TYPE FACILITY ADDRESS 9488 19th Street 850 CrTY CA DATELIC422SENT 111512012 PENALTY PCA CODE 84035 ZIP CODE STATE Rancho Cucamonga 09 I H309 91701 I FACILITY NUMBER 364809858 LICENSEE(S) OR UNliCENSED FACJLnY OPERATOR Rancho Heritage School I\OORESS DATE 111512012 9488 19th Street CrTY ZIP CODE STATE Rancho Cucamonga CA 91701 TITlE Licensing Program Manager I The California Health and Safety Code, Sections 1548, 1568.0822, 1569.49, 1596.99, and 1597.62 provides for the imposition of civil penalties against any facility which fails to take corrective action within prescribed time periods. The California Health and Safety Code, Sections 1547, 1568.0821, 1569.485, 1596.89, 1596.891 and 1597.61 provides for the imposition of civil penalties against any unlicensed facility which fails to lake corrective action within prescribed time periods. The California Health and Safety Code, Sections 1522, 1568.09, 1569.17, 1596.871, and 1596.8712 provides for the imposition of immediate civil penalties against any faciiity which fails to comply with fingerprinting or other criminal background requirements. Your facility has been found in violation of Community Care Licensing statutes and regulations. Failure to correct the deficiency(ies) cited on the Licensing Report (LIC 809 or LIC 9099) daled,_6_1_2_01_2_0_12_ _ _ _ _ __ has resulted in the following civil penalty assessment of: Penalty Amount Due ..................................... ---------------"$6::.0;:;0:.:·.::.00;:. Less Payment(s) Received ................................ -----------------'$-=3.::.0.::.0.-=0.::.0 BALANCE OUE . ........................................ --------------"-$=-30::.:0::c.O=O Send the enclosed copy of this notice and your payment to the address shown below within 10 days. MAKE CHECKS PAYABLE TO THE CALIFORNIA DEPARTMENT OF SOCIAL SERVICES. Please write your invoice and facility number(s) on your check. Department of Social Services Community Care Licensing 3737 Main Street, Suite 700 Riverside, CA 92501 FAILURE TO PAY CIVIL PENALTY MAY RESULT IN ANY OR ALL OF THE FOLLOWING: • SMALL CLAIMS COURT ACTION • LICENSE DENIAL, SUSPENSION, OR REVOCATION • SEIZURE OF PERSONAL INCOME TAX REFUNDS LIC 422(3102} (PUBLIC) STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES A!_ CIVIL PENALTY LEDGER PAYMENT, REDUCTION, OR WAIVER RECORD DISTRICT OFFICE NUMBER 09 I INVOICE NO. __o9_0_29_2_7_ _ _ _ _ _ _ __ FACILITY NAME ; Ii=R"'a"'n""c"'h"'o"'H"'e,-r_ita--'g"-e_S_ch_o_o_I_ _ _ _ _ _ _ _ _ _ _ _ _ _ I J FACILITY ADDRESS 9488 1 9th Street Rancho Cucamonga FISCAL YEAR 2011/2012 uc 422 sEr~T- ~- - -- [11/5/2012 FACILITY PCA COO::; FACILITY TYPE 184035 850 CA 1 DATE H309. 91701 IFAC,UTY NUMBER 364809858 LICENSEE(S) I Rancho Heritage School ADDRESS I 9488 19th Street CITY ZIPCOOEl STATE ' Rancho Cucamonga CA 91701 DATE ioriginal.lnvoice Amount ' I AMOUNT I 06/20/2012 $600.00 I CUMULATIVE BALANCE ~~~~~~--------~~--------~~-------~- llcoo·-,v-il-cP:-e-on"'"al-ty7W--a"'iv_e-cr--cc--------+'-----·--·--l--,Penalty Review Reduction · i IP~e-n-a-:1:-ty:-R;o;-ev-:i-ew--;R=:-eduction Payment 2--- ~ J __ I ~-·- -- ! !Payment 1 ·------- $600.00 -----f--· 11/02/2012 $300.00 I $300.00 ·------T-- I 1=-----=-- - - - - - - - - - + - - - - - - - + - - - - - - - - - - : - - - . ·- -- rayment 3 Payment 4 Payment 5 !BALANCE ! !COMMENTS: II UC 422A (5101) $3oo.oo I $300.00 STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICE COMMUNITY CARE LICENSING DIVISION CASH STATE RECEIPT FOR FEE TYPE PAID: CIVIL PENALTV THESE FEES ARE NON-REFUNDABLE FACILITY NUMBER REMITTER PCA PAY TYPE DATE OF CHECK CHECK NUMBER TOTAL AMOUNT COLLECTED 364809858 Rancho Heritage School 84035 Check 1110212012 0086754133 $300.00 RECEIPT NO: DATE ISSUED: OFFICE: R09-000243317 1110512012 09 filE COPV STATE OF CALIFORNII\- HEALTH AND HUMAtl SERViCES AGENCY CAUfO.!;!NIA DEPARTMENT OF SOCIAL SERVICES NOTICE OF CIVIL PENALTIES DUE 0 !;a Initial Invoice INVOICE NO. Final Notice DISTRICT OR COUNTY OFFICE NUMBER 09/H309 0902833 FACiliTY NAME FISCAL YEAR J DATE UC 422 SENT Rancho Heritage School 2011/2012 1 FACILITY ADDRESS FACILITY TYPE 850 9488 19th Street STATE CITY Rancho Cucamonga CA 04/25/2012 1?fNAL1Y PCA CODE f 84035 Zl? CODE I 91701 FACILITY NUMBER I LICENSEE($) OR UNLICENSED FACILITY OPERATOR Rancho Heritage School 364809858 I ADDRESS iOATE STATE Rancho Cucamonga I 04/25/2012 I 9488 19th Street CITY CA ~COO£[ 91701 ' 1 Licensing P~_·_Man __ ag""e_r_l_ _ _ ___, The California Health and Safety Code, Sections 1548, 1568.0822, 1569.49, 1596.99, and 1597.62 provides for the imposition of civil penalties against any facility which fails to take corrective action within prescribed time periods. The California Health and Safety Code, Sections 1547, 1568.0821, 1569.485, 1596.89, 1596.891 ami 1597.61 provides for the imposition of civil penalties against any unlicensed facility which fails to take corrective action within prescribed time periods. The California Health and Safety Code, Sections 1522, 1568.09, 1569.17, 1596.871, and 1596.8712 provides for the imposition of immediate civil penalties against any facility which fails to comply with fingerprinting or other criminal background requirements. Your facility has been found in violation of Community Care Licensing statutes and regulations. Failure to correct the deflciency(ies) cited on the Licensing Report (LJC 809 or LJC 9099) dated_0_2!03!2 _ _o_1_2_ _ _ _ __ has resulted in the following civil penalty assessment of: Penalty Amount Due ..................................... ----------------'$'-'3'-'0-'-0'-'.0-'-0 Less Payment(s) Received ................................ -----------------'$'-'0-".0'-'--0 BALANCE DUE ......................................... ---------------"$'="30'-"0"-'.0"'-0 Send the enclosed copy of this notice and your payment to the address shown below within 10 days. MAKE CHECKS PAYABLE TO THE CALIFORNIA DEPARTMENT OF SOCIAL SERVICES. Please write your invoke and facility number(s) on your check. Department of Social Services Community Care Licensing 3737 Main Street, Suite 700 Riverside, CA 92501 FAILURE TO PAY CIVIL PENALTY MAY RESULT IN ANY OR ALL OF THE FOLLOWING: • SMALL CLAIMS COURT ACTION • LICENSE DENIAL, SUSPENSION, OR REVOCATION •--SE.IZ.URE-Of-.P-ERSONAUNCOME.TAX..REEUliiD.S UC 42213.'021 (PUBLIC) STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AG, CALIFORNIA DEPARTMENT OF SOCIAL SERVICES CIVIL PENALTY LEDGER PAYMENT, REDUCTION, OR WAIVER RECORD INVOICE N0. _ _:::09:::0.:::27:.:::5:_8_ _ _ _ _ _ __ FACILITY NAME ASCAL YEAR Rancho Heritage School 2011/2012 FACILITY ADDRESS FACILITY T'r'PE 9488 19th Street CITY Rancho Cucamonga DISTRICT OFFICE NUMBER 09/ H309 CA 04/25/2012 FACILITY PCA CODE 84035 850 STATE DATE LIC 422 SENT ZIP CODE 91701 IFACILITY NUMBER LICENSEE(S) Rancho Heritage School 364809858 I ADDRESS 9488 19th Street CITY Rancho Cucamonga STATE CA ZIP CODE 91701 DATE AMOUNT CUMULATIVE BALANCE Original Invoice Amount 02/03/2012 $300.00 $300.00 $300.00 $300.00 Civil Penalty Waiver I Penalty Review Reduction Penalty Review Reduction I Payment 1 Payment 2 Payment 3 Payment 4 I I Payment 5 BALANCE I ~COMMENTS: UC422A(5101) STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING O!VISION FACILITY EVALUATION REPORT (Cont) CCLO Regional 0/flce, 3737 MAIN ST., SUITE 700 RIVERSIDE. CA 92501 FACILITY NAME: RANCHO HERITAGE SCHOOL DEFICIENCY INFORMATION FOR THIS PAGE: FACILITY NUMBER: 364809858 VISIT DATE: 02/03/2012 Deficiency Type POC Due Date I DEFICIENCIES PLAN OF CORRECTIONS(POCs) Section N~mber Type A 02/03/2012 Section Cited 101171(a) Type A 02/03i2012 Section Cited 101170(a) 1 2 3 4 5 6 7 Fire Clearance. All child care centers shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection or the State Fire Marshal. Facility has been using the second level of the building for 2 hours each day for preschool dance activities. The Department did not 8 9 10 11 12 13 14 approve or license the second level of the building for preschool-age children and there is no fire clearance allowing preschool-age children to use any area upstairs. On 1/20/2012, while using one for the rooms upstairs, a child tripped when the child was about to walk up the stairs to the auditorium. 1 Licensee shaH immediately cease using upstairs for 2 preschool activities. A written statement of 3 understanding signed by licensee and all staff 4 members will be submitted to CCL. 5 6 7 8 9 10 11 12 13 14 1 CONTINUATION 2 3 The child fell face down, hit against the stairs, broke 1 2 3 4 the front tooth and received cuts on the lips. An 5 immediate civil penalty of $150 per day for fire 6 clearance violation and $150 per day for violation 7 resulting in injury was assessed. 4 1 2 3 1 2 3 4 5 6 7 4 5 6 7 5 6 7 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: Marianne Donley TELEPHONE: (951) 782-4200 LICENSING EVALUATOR NAME: Ki Ying Kim Leung TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2012 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2012 This Notice must be posted for 30 days UC809 (FAS)- (06104) Page: 1 of 1 STATE OF CALIFORNIA· HEALTH foND HUMAN SERVICES AGb' NN!.~ ;~~;;;~~=::~~~cho~-------·--·-----------r~;ncho cucamonga DI\TE 312 Lo3fD ~~:,--~~;~~~·---- --- -----~---------------------+----------------i • - - - - - - - - - - - --- FACIUr~ UCENSEE(SJ 1 364-809858 Rancho Heritage Schoc' A Licensing Report !L'C SO~ or LIC 9099) was issued on -'0"'21"0'-'3"'12"0"1:':2'=:----- giving notice that your facility has been lound in DATE violation of one or mo~-= re-::!J!rements for which an immediate civil penalty is warranted in accordance wit; one or more of t11e following California H~aitn and Safety Code Sections: 1548, 1568.0822, 1569.49, 1596.99 and 1597.56. You are hereby not.f e': t~ct ao 1o->mediate civil penalty of $150 per violation followed by $150 per day ;o=- '-::>a bon until corrected through for the following vio!aLo"s: is assessed for the p,;· :r: of 02!03'2012 DATE ~: :~s .•.-n,ch result in injury, sickness or death of a client in care. (Does not Fa:: it;es for the Chronically Ill or Foster Family Homes.) ,.( \ : 7_ ;:,-e c-eacance violations (Does not apply to Family Child Care Homes.) e.;:;o, :: =oss:oential Care Absen::e of supervision A.:::?ss·bie bodies of water .:.::~2s-·bie f"·sarms, ammunition, or both C. ,,-so; a2ent refused entry to a facility or any part of a facility The presence of an excluded person on the premises 2 Total it of (Per Day ) Vioiations: X S150 $ 300.00 Total Penalty Assessed YOU WILL RECEIVE AN INVOICE IN THE MAIL. DO NOT SEND MONEY UNTIL YOU RECEIVE YOUR INVOICE NAME Of t.ICENSlNG PROG~M.' :..:~:.__:.·::,· Kim Leung ·- -~--------~- SUPERVISOR ! SIGNATURt: OF LICENSING PROGRAM ANALYST 312012 -~GN~t~i~i~REPRESEr:~--~~--:~--::~=-: ' I - - - - - - - - - - - -· -----------·------------- -· REVIEWISIGI"TU":~' !""! ~ L9 h/) G~;,;;;;--~-------------------··---------___1_____ 0210312012 0 I ;- ) - -· ---- $ - I d-. .____________________ _!_ _ - - - - - - PA;~;;2- STATE OF CALIFORNIA~ HEALTH AND HtJ,..... ~SERVICES AGENCY CA ... rORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office 3737 MAIN ST., SUITE 700 RIVERSIDE, CA 92501 07/19/2012 RANCHO HERITAGE SCHOOL 364809858 9488 19TH STREET RANCHO CUCAMONGA, CA 91701 Letter of Deficiency Citations Cleared Dear Licensee, The following deficiencies, initially cited during a visit on 06120/2012, have been cleared: Section Cited: 101163(a) Date Due: 06/2112012 Plan of Correction: Corrections: Clearance Date: Licensee will review the regulation, Section 101163 with all staff members and submit a written statement with staff signatures by 6/2112012. Received statement. 0711212012 LICENSING EVALUATOR NAME: Kim Leung TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2012 This report must be available at Child Care and Group Home facilities for public review for 3 years. C/earedPOC Letter(FAS)~(04105) Page: 1 of2 STATE OF CALIFORNIA. HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office 3737 MAIN ST., SUITE 700 RIVERSIDE, CA 92501 07/19/2012 RANCHO HERITAGE SCHOOL 364809858 COMMENTS Please be advised of the following requirement per California Health & Safety Code: Per Section 1596.8595(b) the licensee shall post the "Letter of Deficiency Citations Cleared" verifying the licensee's compliance or noncompliance with the department's order (LIC809D or LIC 9099D) to correct a type A deficiency that is subject to posting for a period of 30 days. The "Letter of Deficiency Citations Cleared" shall be posted immediately upon receipt, immediately adjacent to, the interior side of the main door into the facility and shall be posted for a period of 30 consecutive days. Failure to comply shall result in an immediate civil penalty of one hundred dollars ($1 00). LICENSING EVALUATOR NAME: Kim Leung TELEPHONE: (951) 529-4713 LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2012 This report must be available at Child Care and Group Home facilities for public review for 3 years. Cleared POC Letter (FAS) · (06/04} Pilgn: 2 of 2 L.I\LWVHNIA Ut::I'AH ll.'ltN I U>" ::0Ul..;jf\.l ::i!::H\IIt;L:;::; CIVIL PENALTY LEDGER PAYMENT, REDUCTION, OR WAIVER RECORD INVOICE NO. __os_o_28_3_3_ _ _ _ _ _ _ __ DISTRICT OFFICE NUMBER 09/ H309 r;\:IUTYNAME--------------------, FJScAL YEAR ' Rancho Heritage School Ft-,~JUTY < 201112012 ADDRESS Rancho Cucamonga 1 -~ 85o STATE 1 . o7/23/2012 FACILITY TYPE : 9488 19th Street CA - - - -~ DATE UC 422 SENT FACILITY PCA-C0of- 1 ---- 84035 _ -~ . 1 ZJPCOOE 91701 I ] LICENSEE($) - Rancho Heritage School 1 AcDRESS·.,---~-------- ----1 ·' 9488 19th Street 'ciTY P.ancho Cucamonga ZIP CODE STATE CA 91701 ·_·----------------,,==~--"D""AT"'E=-._ _-'---~A,.,M"-'O=U,NT.,___·_·-~j_ CUMULATIVE BALANCE )riginal Invoice Amount ·1 1 1 .,~!~ ~ - e"na"l-ty,. .w_a,i~ve-,r,- -~ -~ - -~ - ~ ~- - -~ ~ :~02~/~03~/~2-0_1~2- ~ -~- - - -~ ~ ~ ~ ~- $-3-_0_~_:~_o_-+~-~~~-~~----- $W] c;("nalty Review Reduction -~,e-:c-n:-cac-.-ltc--y•R'e-v'ie-w---;oR""e-d""u-c"'tio-n I , --------~-----------------+---·-- ...... ·---' i I ... ---' : 7/23/2012 . $300.00 - .. $0.00 ! ---- ! I . ,---~------------~---------~----·- 'Payment 4 t.Jayment 5 ::>A LANCE I i l------I ,~-- $0 ------. ;QMMENTS: 7/23/2012 check number is 0049159921 't.,; 422A (5101) I I ......-.j $0.00 1 STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICE COMMUNITY CARE LICENSING DIVISION CASH STATE RECEIPT FOR FEE TYPE PAID: CIVIL PENALTV THESE FEES ARE NON-REFUNDABLE FACILITY NUMBER REMITTER PCA PAY TYPE DATE OF CHECK CHECK NUMBER TOTAL AMOUNT COLLECTED 364809858 Rancho Heritage School 84035 Check 07/23/2012 0041959921 $300.00 RECEIPT NO: DATE ISSUED: OFFICE: R09-000234254 07/23/2012 09 CALIFORNIA OEPAIUMENT OF SOaAL SERVICES bZi INVOICE NO. 0 Initial Invoice Final Notice DISTRICT OR COUNTY OFFICE NUMBER 09/ H309 0902758 FACilllY NAME FISCAl YEAR Rancho Herttage School FACILITY ADDRESS 9488 19th Street 2011/2012 05/08/2012 FACilllYTYPE PENIILIY PCI\ CODE 850 STATE CITY Rancho Cucamonga CA DATE UC 422 SENT 84035 ZIP CODE 91701 lFI\CllllY NUMBER 364809858 UCENSEE(SJ OR UNLICENSED FACILITY OPERI\l"OR Rancho Herttage School ADDRESS OAT£ 9488 19th Street 05/08/2012 CITY STATE Rancho Cucamonga CA ZIP CODE 91701 Licensing Program Manager I The California Health and Safety Code, Sections 1548, 1568.0822, 1569.49, 1596.99, and 1597.62 provides for the imposition of civil penalties against any facility which fails to take corrective action within prescribed time periods. The California Health and Safety Code, Sections 1547, 1568.0821, 1569.485, 1596.89, 1596.891 and 1597.61 provides for the imposition of civil penalties against any unlicensed facility which fails to take corrective action within prescribed time periods. The California Health and Safety Code, Sections 1522, 1568.09, 1569.17, 1596.871, and 1596.8712 provides for the imposition of immediate civil penalties against any facility which fails to comply with fingerprinting or other criminal background requirements. Your facility has been found in violation of Community Care Licensing statutes and regulations. Failure to correct the deficiency(ies) cited on the Licensing Report (LIC 809 or LIC 9099) dated._o_2i_0_3_i_20_1_2_ _ _ _ __ has resulted in the following civil penalty assessment of: Penalty Amount Due ..................................... -----------------"-$-=-30-=-0'-'.-=-00"Less Payment(s) Received ................................ ----------------"$:o::3:::.00o::·:::.O:::.O BALANCE DUE ......................................... - - - - - - - - - - - - - - " $ " ' - 0 . = 0 0 Send the enclosed copy of this notice and your payment to the address shown below within 10 days. MAKE CHECKS PAYABLE TO THE CALIFORNIA DEPARTMENT OF SOCIAL SERVICES. Please write your invoice and facility number(s) on your check. Department of Social Services Community Care Licensing 3737 Main Stree~ Suite 700 Riverside, CA 92501 FAILURE TO PAY CIVIL PENALTY MAY RESULT IN ANY OR ALL OF THE FOLLOWING: • SMALL CLAIMS COURT ACTION • LICENSE DENIAL, SUSPENSION, OR REVOCATION • SEIZURE OF PERSONAL INCOME TAX REFUNDS liC A22 (3102) (PUBLIC) STAlE OF CAUFORNIA- HEIIllH AND HUMm SERVICES AGE CALIFORNIA DEPARTMENT OF SOCIALSEFIVJCES CIVIL PENALTY LEDGER PAYMENT, REDUCTION, OR WAIVER RECORD INVOICE NO. _ _:_o9:.:0.=.27:..:5_:_s_ _ _ _ _ _ __ FACJlfiY NAME FISCAl YEAR Rancho Heritage School FAClUTYlYPE 9488 19th Street Rancho Cucamonga DillE UC 422 SENT 05/08/2012 2011/2012 FACIUTY ADDRESS CrTY DISTRICT OFFICE NUMBER 09/ H309 FACIUTY PCA CODE 84035 850 ZII'COOE STI(JE CA 91701 UCENSEE(S) IFACIUTY NUMBER Rancho Heritage School I . 384809858 ADDRESS 9488 19th Street CrTY Rancho Cucamonga STA'!E CA ~?CODE 91701 DATE CUMULATIVE BALANCE AMOUNT Original Invoice Amount 09101/11 $300.00 $300.00 513112 ck0018402180 $300.00 $0.00 $0.00 $0.00 Civil Penalty Waiver Penalty Review Reduction Penalty Review Reduction Payment1 Payment 2 Payment3 Payment4 PaymentS BALANCE COMMENTS: uc ~22A (5.'01) STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICE COMMUNITY CARE LICENSING DIVISION CASH STATE RECEIPT FOR FEE TYPE PAID: CIVIL PENALTY THESE FEES ARE NON-REFUNDABLE FACILITY NUMBER REMITTER PCA PAY TYPE DATE OF CHECK CHECK NUMBER TOTAL AMOUNT COLLECTED 364809858 Rancho Heritage School 84035 Check 05/03/2012 0018402180 $300.00 RECEIPT NO: DATE ISSUED: OFFICE: R09-000228090 05/08/2012 09 STAlE OF CAUFORNIA- HEALTH Ah. AAN SERVICES AGENCY 1UFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSING DIVISION ~gt,_Q R!!~lo~~Jli Qffiq~" ~ ~ _ 8737 MAIN ST,; SbiiTE; 7!19 RIVERSIDE, CA 92501 02109/2012 RANCHO HERITAGE SCHOOL \!!!4!l0il~HJS 9488 19TH STREET RANCHO CUCAMONGA, CA 81701 l:iiftii' of I'Jifllllii'iiiii Glf~fiBi'iii Gliiii'itl Dear LicenSee, The following deficiencies, initially cited during a visit on 02/03/2012, have been cleared: Plan·of"OcrrectiO.rf: · - Cemictioi1s!- Clearance Uate: licensee shall immediately cease using upstairs for preschool activities. A written statement of understanding signed by licensee Completed 02/03/2012 Section Cited: 101170(a) Plan of Correction: Date Due: 02/03/2012 Corrections: Completed. Clearance Date: 02/03/2012 ana a!Lstaff mejjit1Brs_~u ge suo.mii!OO 10 c~L LicENSING EVALUATOR NAME: Kl Ying Kim LeJng teLEPHONE: (951) 5294713 LICENSING EVALUATOR SIGNATURE: This report must be available at Child Care and Group Home facilities for public review for 3 years. Cleared POC lelter(FAS) -(04105) Page: 1 of 2 STATE OF CAUFORNIA ~HEALTH M ~UFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE UCENSING DMSION MN SERVICES AGENCY GCLD Ri!!~ionai OI!Jce 3737 MAIN s'f., SliiTE 796 RIVERSIDE, CA 92501 02/99/2012 RANCHO HERITAGE SCHOOL 364809858 Gl!lMMI!!N'fl! Please be advised of the following requirement per California Health & Safety Code: ~er Seoiion 1ii9!!.8fi91:i(bi ihelioen;;ee iihi!ll,pl'!:3l !~e "Leiier of De(icien(:Y, }:Jfi;l]il'!m; QJe!lf!l~'~verifying !he licensee's compliance or noncompliance with the department's order (LiCB09D or Lie 90990) to correct a type A deficiency that is subject to posting for a period of 30 days. immecli!l~!Y adjacent to, the interior side of the main door into the facility and shall be posted for a period oi 3(} consecutive days. fhe nkei:ier of Deficiem::y Qiiaiio.ns Cie.ared'' shall be pps4;;ti immedia\