300614114-7-21-2021-06-CC-STOE-C55NFS-20210721102601

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 300614114
Report Date: 07/21/2021
Date Signed: 07/21/2021 10:26:07 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 PRESCHOOL		FACILITY NUMBER:	300614114
ADMINISTRATOR:	NOORZAD, TINA		FACILITY TYPE:	850
ADDRESS:	24242 LA CRESTA		TELEPHONE:	(949) 496-6151
CITY:	DANA POINT	STATE: CA	ZIP CODE:	92629
CAPACITY:	24	CENSUS: 0	DATE:	07/21/2021
TYPE OF VISIT:	Case Management - Licensee Initiated	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Lauren Pattullo		TIME COMPLETED:	10:34 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	An unannounced case management inspection was conducted on this date by Licensing Program Analyst (LPA) Stacy Torrence for the purpose of adding a room. The facility has requested to add classroom P-12 to their license. The facility is currently licensed for 24 children and is requesting an increase in capacity to 48 children. The facility is currently licensed for classrooms P5 only. The facility is located on the Richard Henry Dana Elementary School campus and is a state preschool. LPA Torrence met with Lauren Pattullo, Director of Early Childhood General and Special Education Programs, who guided analyst on a tour of the facility. The facility was closed for the summer; therefore, there were no children or staff present. Operations hours are Monday-Friday; an AM session: 8:00 a.m.-11:00 a.m. and PM session: 12:15 p.m.-3:15 p.m., serving children ages 3-5 years old. Waiver for shared playground and restrooms on file. A review of staff records on this date indicates that all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions. All areas identified on the Facility Sketch were inspected. If children become ill during the day, they will rest in the isolation area located, in the front office, where there is either a health clerk or LVN present. The bathroom in the health office will be used for the ill children. Medication will be stored in the health office and in the classroom, in a locked box. Furniture and equipment were inspected for age appropriateness and good repair. Age appropriate sinks and toilets were inspected for availability, good repair, water temperature, toilet paper, paper towels, area safety and sanitation. Children bring their own water bottles from home and the school provide water, if needed. Children are able to refill their bottles in classroom by a water dispenser. First Aid supplies were inventoried. Sign in / sign out record meets regulation requirements. School provides free meals for all the students. Facility pick up the food at the cafeteria, located on campus. Continue on next page (1 of 2)

SUPERVISOR'S NAME: Thuy Ho	TELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Stacy Torrence	TELEPHONE: (714) 300-3599
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021

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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: CAPISTRANO USD/R.H. DANA STATE PRESCHOOL	FACILITY NUMBER: 300614114
	VISIT DATE: 07/21/2021

NARRATIVE

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Indoor Activity Space Measurements:
Classroom #P-5: 40 x 22.11 = 884 sqft.
Classroom #P-12: 40 x 22.11 = 884 sqft.- Added Room
Total= 1,769 sqft. divided by 35 = 50 children

Total children toilets and sinks:
toilets 8 x 15 = 120 children
sinks 4 x 15 = 60 children

Outdoor Activity Space Measurements:
Preschool children have a waiver to share elementary school playground; which has sufficient amount of square footage to accommodate the requested 48 children.
Playground is completely enclosed. Outdoor activity area is supplied with age and size appropriate equipment. An adequate amount of cushioning material(wood chips) is in place under the equipment. Shade is provided by a mature tree. Drinking water is available by children bringing their water bottles from home and a water jug is available for refills

Fire clearance approval letter on file and dated 05/28/2021, adding room #P-12.

Facility provides Incidental Medical services.

LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian

In the areas evaluated, no deficiency was observed and cited today per CA Code of Regulations, Title 22, and Division 12.

Exit interview was conducted. A copy of this report and appeal rights were discussed and provided to the director. The Notice of Site Visit was posted. The director was informed that the Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100.

End of Report

SUPERVISOR'S NAME: Thuy Ho	TELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Stacy Torrence	TELEPHONE: (714) 300-3599
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021

LIC809 (FAS) - (06/04)

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