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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274413124
Report Date: 09/04/2024
Date Signed: 09/09/2024 08:58:04 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/09/2024 08:58 AM - It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:PACIFIC GROVE UNIFIED SCHOOL DIST./STATE PRESCHOOLFACILITY NUMBER:
274413124
ADMINISTRATOR/
DIRECTOR:		DIANE M. BERONFACILITY TYPE:
850
ADDRESS:1004 DAVID AVENUETELEPHONE:
(831) 646-6547
CITY:PACIFIC GROVESTATE: CAZIP CODE:
93950
CAPACITY: 16TOTAL ENROLLED CHILDREN: 16CENSUS: 10DATE:
09/04/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Diane M. Beron TIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Andrea Cortez an unannounced Required - 1 Year Inspection. The purpose of today’s visit is to ensure the facility is in compliance with Title 22 California Code of Regulations. LPA met with the Site Supervisor(SS) Faton Kine Samuels, and explained the nature of today's visit. LPA toured the Facility both inside and outside during todays visit. LPA noted that the Facility is located on the Pacific Grove Community High School Campus Adult Education Program, in room A. LPA observed the required posted materials, including the Facility License, Emergency Disaster Plan (LIC 610), Earthquake Preparedness Checklist (LIC 9148), Parents' Rights Poster (PUB 393), Personal Rights (LIC 613A), Child Car Seat Law (PUB 269), and Activity Schedule. The facility has two class sessions: morning 8:30am-11:30am, afternoon 1:00pm- 4:00pm. Both sessions operate Monday – Friday.

LPA reviewed six children's and 1 staff files during today's inspection. Each child's file reviewed contains the Information and Emergency Information form (LIC 700), immunization records, physicians report, personal rights, and parents rights. All staff have clearance through Pacific Grove Unified School District (PGUSD). All staff files contain the required transcripts/verification of experience. All staff's CPR and First Aid certifications are current. The Site Supervisor understands that there shall be at least one person with valid CPR and First Aid certifications on site at all times, or present during off-site activities (field trips).

Site Supervisor (SS) understands the conditions, limitations, and capacity specifications of the Facility license. SS understands that children shall be visually supervised at all times. LPA observed that all rooms are in order. Drinking water is readily available for the children in each room and in the outdoor playground area via water dispensers, and cups. LPA observed solid waste containers with tight-fitting lids in each room. Staff and children's bathrooms are clean and have sufficient supplies. There is a separate staff bathroom not utilized by the children which an isolated child can use if needed. SS states that there are no weapons or firearms on the premises.

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Andrea Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: PACIFIC GROVE UNIFIED SCHOOL DIST./STATE PRESCHOOL
FACILITY NUMBER: 274413124
VISIT DATE: 09/04/2024
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LPA observed all furniture and equipment is in good condition and safe for the children. The playground area utilized by children is surrounded by appropriate fencing. The facility has an active waiver posted for shared playground space. LPA observed that the outdoor equipment is age appropriate. LPA did not observe any bodies of water.

SS states the children bring their snacks from home, however, the district can provide pre-packed snack when needed. Cleaning supplies are securely stored and inaccessible to the children. LPA observed a fully charged 2A10BC fire extinguisher and working smoke/carbon monoxide detectors. Director states that the Facility does not administer medications at this time.



Clearances for individuals at this facility who require caregiver background checks are issued by State Department and/or County Office of Education and do not come under the jurisdiction of Community Care Licensing Division.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Childcare Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

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



No deficiencies cited, exit interview conducted and report was reviewed with the Site Supervisor Faton Kine Samuels.

A notice of site visit was given and must remain posted for 30 days.

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Andrea Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024
LIC809 (FAS) - (06/04)
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