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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300614114
Report Date: 01/10/2020
Date Signed: 01/10/2020 11:15:43 AM

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:CAPISTRANO USD/R.H. DANA STATE PRESCHOOLFACILITY NUMBER:
300614114
ADMINISTRATOR:NOORZAD, TINAFACILITY TYPE:
850
ADDRESS:24242 LA CRESTATELEPHONE:
(949) 496-6151
CITY:DANA POINTSTATE: CAZIP CODE:
92629
CAPACITY:24CENSUS: 21DATE:
01/10/2020
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Tina Noorzad TIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA), Connolly, conducted an unannounced annual inspection of the facility on today's date. Upon arrival the LPA met with site facilitator Tina Noorzad who accompanied the LPA on a tour of the facility which included a tour of the playground, walkways, bathrooms and classroom. Census was taken. There were 21 children in care with three attending staff. Facility is operating within ratio and capacity.

Tina Noorzad explained that currently preschool is in session, Monday through Friday 8:00 AM to 11:00 AM in Portable #5, September thru June. There is no afternoon session.

LPA inspected the following areas: availability of drinking water, age appropriate sinks and toilets, water temperature, toilet paper, paper towels, medication policy and furniture & equipment, outdoor equipment (safety, cushioning material, good repair, and age appropriateness, required shade, drinking water and fencing), teacher child ratios (staff names recorded), care and supervision, sign in and out sheets. Food preparation areas were reviewed for cleanliness. Food supply storage areas were reviewed for protection against contamination.
Children records were reviewed for identifying information and medical assessment. Staff files were reviewed for health screening documentation and verification of current CPR/First Aid training (current till 5/20/21)
During today’s visit LPA discussed incidental medical services with the site facilitator who said there are no incidental medical services being provided at this time.
An updated Emergency Disaster Plan and an updated Personnel Report was provided.

After a tour of the center and review of children's and staff records, no deficiency was observed.
Exit interview was conducted. Licensing report reviewed and discussed. The Notice of Site Visit was posted. Facility representative was informed that the notice of site visit must be posted for 30 consecutive days. Failure to post will result in civil penalty of $100. Appeal Rights were provided.
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Gesine ConnollyTELEPHONE: (714) 293-9314
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2020
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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