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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197414967
Report Date: 05/27/2022
Date Signed: 05/27/2022 03:52:45 PM


Document Has Been Signed on 05/27/2022 03:52 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245



FACILITY NAME:CAPISTRANO ELEMENTARY SCHOOL PRESCHOOLFACILITY NUMBER:
197414967
ADMINISTRATOR:GIBBS, ALICEFACILITY TYPE:
850
ADDRESS:8118 CAPISTRANO AVENUE ROOM #1TELEPHONE:
(818) 883-8981
CITY:WEST HILLSSTATE: CAZIP CODE:
91304
CAPACITY:24CENSUS: 14DATE:
05/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Juani AliTIME COMPLETED:
04:00 PM
NARRATIVE
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On 5/27/2022 Licensing Program Analyst (LPA) Doris Whitmore, conducted an unannounced Annual Required Inspection for the preschool license. LPA met with Juani Ali and toured the facility indoors and outdoors. Days and hours of operation are Monday- Friday. This is a half day program with an am and pm session. am session starts at 8:15a.m. to 11:15a.m. and the p.m., session starts at 12:15p.m. to 3:15p.m. LPA observed 14 children in care. Children don’t nap in the program. Am children eat breakfast and pm children eat lunch.

There is no swimming pool or other bodies of water on the premises. There are no firearms or ammunition allowed or stored on the premises. Disinfectants, cleaning solutions, medication and other hazardous items are made inaccessible. All poisons are kept in a locked storage area. No poisons were observed during the inspection.

Furniture and equipment are in good condition, free of sharp, loose or pointed parts. Playground equipment is in safe condition, free of sharp, loose or pointed parts. The surface of the outdoor activity space is maintained in a safe condition and is free of hazards. All toilets and handwashing facilities are in safe and sanitary operating condition. Floors in the facility are clean and safe. All kitchen, food preparation and storage areas are clean, free of litter/rubbish and free of rodents/vermin. All foods/beverages capable of rapid spoiling are stored in covered containers at 45 degrees F or less. Solid waste storage containers have tight-fitting covers and are in good repair. Solid waste storage containers have tight-fitting covers and are in good repair. Drinking water is available both indoors and outdoors. Areas around high climbing equipment, swings and slides have cushioning material to absorb falls. All materials and surfaces accessible to children are toxic free. Page1

SUPERVISOR'S NAME: Claudia EscobedoTELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Doris WhitmoreTELEPHONE: 424-301-3029
LICENSING EVALUATOR SIGNATURE:
DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: CAPISTRANO ELEMENTARY SCHOOL PRESCHOOL
FACILITY NUMBER: 197414967
VISIT DATE: 05/27/2022
NARRATIVE
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.The facility is free of flies, insects and rodents. Facility has one or more functioning carbon monoxide detectors that meet statutory requirements. Prior to working or volunteering in a licensed child care facility, all individuals subject to a criminal record review have received a criminal record clearance or exemption. No individuals excluded by the Department are allowed to be present. Capacity and limitations as specified on the license are being maintained The name of the child care center director or fully-qualified teacher(s) designated to act in the director’s absence has been reported to the Department. All children are under supervision, including visual supervision, of a teacher at all times. Facility maintains a ratio of one teacher supervising no more than 12 children in care. Menus are posted at least one week in advance where an authorized representative can view them.

Incidental Medical Services (IMS) are currently being provided. Licensee is aware that an IMS plan is required to be submitted to the licensing office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA Information line at (800) 514-0301(voice), (800) 514-0383 (TDD) and website link https://www.ada.gov/childqanda.htm.


The following item should be posted on the board: PUB 269 Child passenger restraint system poster Page2
SUPERVISOR'S NAME: Claudia EscobedoTELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Doris WhitmoreTELEPHONE: 424-301-3029
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: CAPISTRANO ELEMENTARY SCHOOL PRESCHOOL
FACILITY NUMBER: 197414967
VISIT DATE: 05/27/2022
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LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following deficiency is being cited: (see next page, 809 D) Licensee was provided a copy of their appeal rights.

This report shall be made available to the public upon request. LIC 9213 Notice of Site Visit and the Appeal Rights is provided and required to be posted for 30days. Page 3

SUPERVISOR'S NAME: Claudia EscobedoTELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Doris WhitmoreTELEPHONE: 424-301-3029
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 05/27/2022 03:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245


FACILITY NAME: CAPISTRANO ELEMENTARY SCHOOL PRESCHOOL
FACILITY NUMBER: 197414967

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.954
Licensure Requirements
Every licensed child day care center shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [1t] out of [1] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/06/2022
Plan of Correction
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To reach out to Mainteance and Operation and ask How to proceed? Facility will purchase and install and send proof of picture by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Claudia EscobedoTELEPHONE: (424) 301-3044
LICENSING EVALUATOR NAME: Doris WhitmoreTELEPHONE: 424-301-3029
LICENSING EVALUATOR SIGNATURE:
DATE: 05/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4