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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304312940
Report Date: 08/06/2024
Date Signed: 08/06/2024 03:47:34 PM

Document Has Been Signed on 08/06/2024 03:47 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:SONEJI, MAYURIFACILITY NUMBER:
304312940
ADMINISTRATOR/
DIRECTOR:		SONEJI, MAYURIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 552-5763
CITY:IRVINESTATE: CAZIP CODE:
92612
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 12DATE:
08/06/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:21 PM
MET WITH:Licensee, Mayuri SonejiTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sun visited the facility for a Case Management Deficiency. During inspection LPA observed that licensee’s helper did not have proof of immunization against measles. See LIC 809D for deficiency cited.

Exit interview conducted and appeal rights given.

Exit interview was conducted, and a copy of this report was provided to licensee. Appeal Rights explained. The Licensee was provided a copy of the appeal rights (LIC 9058 01/2016) and their signature on this form acknowledges receipt of these rights. First level appeal is to the Regional Manager address is above on report.

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Cynthia Sun
LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/06/2024 03:47 PM - It Cannot Be Edited


Created By: Cynthia Sun On 08/06/2024 at 03:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: SONEJI, MAYURI
FACILITY NUMBER: 304312940

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/20/2024
Section Cited
HSC
1597.622(a)(1)

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(a) (1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles... This requirement is not met as evidence by:
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Licensee stated they will submit proof of immunization records for helper to the OCRO by 8/20/24.
Licensee stated she will review paperwork.
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Based on record review licensee helper did not have proof of immunization against measels on file for review.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Thuy Ho
LICENSING EVALUATOR NAME:Cynthia Sun
LICENSING EVALUATOR SIGNATURE:
DATE: 08/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2024


LIC809 (FAS) - (06/04)
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