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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313212
Report Date: 11/28/2022
Date Signed: 11/28/2022 12:36:34 PM

Document Has Been Signed on 11/28/2022 12:36 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:LAMBARD, NICOLEFACILITY NUMBER:
304313212
ADMINISTRATOR:LAMBARD, NICOLEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 682-6233
CITY:RANCHO STA MARGARITASTATE: CAZIP CODE:
92688
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 12DATE:
11/28/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Nicole Lambard, Licensee TIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Patricia Duron conducted an unannounced case management investigation for the incident which the facility self reported to licensing office on 11/02/2022. On 11/02/22 licensee called Community Care Licensing to report unusual incident which according to the incident report, occurred at the facility on 11/01/22 at 10:35 am. Licensee stated staff administered Epi Pen and called 911 due to child having an allergic reaction to food, and child began to get welts around the child’s mouth.

LPA toured the facility inside and outside and a census was taken as follow: 4 staff including director with 12 children. A review of staff criminal clearance records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

During today's inspection LPA Duron reviewed files and interviewed 4 staff members. LPA was unable to interview the child due to the child being non-verbal and under 2 years old.

During today's visit licensee provided LPA with incidental medical service plan for child and documentation needed to inform staff of children with allergies. Licensee demonstrated a training epi-pen which staff have used to train with due to children with epi-pens.

Based on the interviews conducted during the investigation, the information obtained, and the areas that were evaluated, NO deficiencies were observed of the California Code of Regulations, Title 22, Division 12 during today’s inspection.

LPA provided licensee with appeal rights. All appeals must be in writing and received by the Regional Office within 15 business days. Appeal Rights were explained. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee.
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Patricia Duron
LICENSING EVALUATOR SIGNATURE: DATE: 11/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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