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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304270114
Report Date: 11/04/2022
Date Signed: 11/04/2022 11:53:49 AM


Document Has Been Signed on 11/04/2022 11:53 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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868



FACILITY NAME:CAPISTRANO UNIFIED SCHOOL DISTRICT-CLARENCE LOBOFACILITY NUMBER:
304270114
ADMINISTRATOR:MORROW, SUSANFACILITY TYPE:
850
ADDRESS:200 AVE. VISTA MONTANATELEPHONE:
(949) 234-5341
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92672
CAPACITY:48CENSUS: 14DATE:
11/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Jessica PonsenTIME COMPLETED:
12:20 PM
NARRATIVE
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Licensing Program Analyst (LPA's), Thompson and Lucero conducted an on site inspection for the purpose of an Annual Random. LPA and Teacher Jessica Ponsen toured the facility inside and outside. The floor and yard plan (LIC 999) were verified. LPA observed a total of 14 preschool age children with 2 staff. Facility hours are Monday through Friday, 8 AM to 3 PM.

During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staffing ratios. A review of the Facility Personnel Report Summary on this date indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

During the inspection of the indoor activity space, LPA was informed the facility is no longer utilizing room #7 which is stated on the license. LPA informed Teacher, LIC 200A Application for a Child Care Center Application needs to be submitted to Community Care Licensing Regional Office. The licensee shall notify the Department in writing of his/her intent prior to making any structural changes that reduce the total amount of indoor or outdoor activity space.

LPA did not observe any items which could pose a danger to children (poisons, detergents, cleaning compounds, medications or hazardous items). The children's bathrooms are clean and sanitary.

During record review, LPA was unable to verify a disaster drill log. Teacher present stated she does not document the drills. Disaster drills shall be conducted at least every six months. The drills shall be documented. This documentation shall be kept in the child care center for at least one year.

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SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 795-0415
LICENSING EVALUATOR NAME: Dean ThompsonTELEPHONE: (714) 287-0708
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2022
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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Document Has Been Signed on 11/04/2022 11:53 AM - 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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868


FACILITY NAME: CAPISTRANO UNIFIED SCHOOL DISTRICT-CLARENCE LOBO

FACILITY NUMBER: 304270114

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101212(c)
(c) The licensee shall notify the Department in writing of his/her intent prior to making any structural changes that reduce the total amount of indoor or outdoor activity space. Such structural changes shall include, but not be limited to, room additions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above. The license issued to the preschool were for rooms #2 and #7. LPA was advised room #7 is no longer being used under license 304270114 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2022
Plan of Correction
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Teacher was advised LIC 200A needs to be submitted to the CCLD Orange County Regional Office by POC due date.
Type B
Section Cited
CCR
101215.1(f)
(f) When the child care center director is absent from the center, arrangements shall be made for a fully qualified teacher as specified in Section 101216.1(c) to act as substitute. This substitute child care center director shall be aware of center operations, including total enrollment; shall be trained in program operation; and shall be designated as an authorized person to correct operational deficiencies that constitute immediate threats to children's health and safety.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. There shall be a clear written statement of the administrative responsibility and authority delegated to the child care center director.

in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2022
Plan of Correction
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The facility will send an LIC 308 Designation of Responsibility to our office so the person can cover the temporarily absence of the director.

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: Judy HansonTELEPHONE: (714) 795-0415
LICENSING EVALUATOR NAME: Dean ThompsonTELEPHONE: (714) 287-0708
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/04/2022 11:53 AM - 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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868


FACILITY NAME: CAPISTRANO UNIFIED SCHOOL DISTRICT-CLARENCE LOBO

FACILITY NUMBER: 304270114

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101174(d)(2)
Disaster and Mass Casualty Plan
(d) Disaster drills shall be conducted at least every six months. (2) The drills shall be documented. This documentation shall be kept in the child care center for at least one year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above. Teacher present stated they do not keep a disaster drill log which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2022
Plan of Correction
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Submit a disaster drill log by POC due date
Type B
Section Cited
CCR
101212(b)
Reporting Requirements
(b) The name of the child care center director, and any fully qualified teacher(s) designated to act in the child care center director's absence, shall be reported to the Department within 10 days of a change of child care center director or designee(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited. Director (S3) listed on the Licensing Information System - Facility Profile is no longer employed at the Preschool and the new director was not reported to CCLD which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2022
Plan of Correction
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Submit documents to CCLD regional office with the qualified Director information

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: Judy HansonTELEPHONE: (714) 795-0415
LICENSING EVALUATOR NAME: Dean ThompsonTELEPHONE: (714) 287-0708
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2022
LIC809 (FAS) - (06/04)
Page: 3 of 6


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: CAPISTRANO UNIFIED SCHOOL DISTRICT-CLARENCE LOBO
FACILITY NUMBER: 304270114
VISIT DATE: 11/04/2022
NARRATIVE
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The outdoor activity space was inspected for compliance. The playground was enclosed by a fence at least four feet in height. The surface of the outdoor activity space was well maintained and free of hazards. The outdoor equipment and toys were in good repair and free of sharp edges. There are no bodies of water present at the facility. The facility grounds were safe, sanitary and in good repair.

Director (S3) listed on the Licensing Information System - Facility Profile is no longer employed at the Preschool. LPA was informed (S3) retired. The name of the child care center director, and any fully qualified teacher(s) designated to act in the child care center director's absence, shall be reported to the Department within 10 days of a change of child care center director or designee(s).

Staff files were reviewed for staff present during the facility inspection this date; During record review, LPA did not observe LIC 308 Designation of Responsibility form in either staff file. LPA did not observe a posted LIC 308 Designation of Responsibility form.

2 staff files were reviewed. Health screening and immunizations as required were reviewed. Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a childcare center if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles for 2 staff were reviewed and within compliance.

Beginning March 31, 2018, H&S Code 1596.8662 requires all directors and employees to complete mandated reporting training, and to renew the training every two years. Staff present had current mandated reporter certification. Aide present possesses current EMSA approved Pediatric CPR/First Aid certifications, which expires 02/2024.

Children's records were reviewed, and there was a separate, complete and current record for each child. A random sample of children's files were reviewed for documentation of the child’s name, address, and telephone number of the child’s authorized representative and of relatives or others that can assume responsibility for the child if the authorized representative cannot be reached when necessary (LIC 700) and a medical assessment. In the areas reviewed the children’s files were found to be in full compliance.

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SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 795-0415
LICENSING EVALUATOR NAME: Dean ThompsonTELEPHONE: (714) 287-0708
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022
LIC809 (FAS) - (06/04)
Page: 6 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: CAPISTRANO UNIFIED SCHOOL DISTRICT-CLARENCE LOBO
FACILITY NUMBER: 304270114
VISIT DATE: 11/04/2022
NARRATIVE
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Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care 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

Teacher was informed that Licensing Quarterly Updates are available at www.ccld.ca.gov director may request to be added to an email list to receive a Quarterly Update by contacting the Child Care Advocate at childcareadvocatesprogram@dss.ca.gov or at www.ccld.ca.gov
LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian

Information on the additional nutrition training, immunization requirements for children, and Health Schools Act (http://www.cdpr.ca.gov/docs/pestmgt/schoolipm.htm) were provided. Teacher was informed, and website given, about the California Child Care Disaster Planhas been posted to the UCSF California Childcare Health Program website: cchp.ucsf.edu/content/disaster-preparedness Also provided was information about the E-Learning Modules available at https://ccld.childcarevideos.org A

LPA discussed the safe sleep regulations with director and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed director of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

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SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 795-0415
LICENSING EVALUATOR NAME: Dean ThompsonTELEPHONE: (714) 287-0708
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022
LIC809 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: CAPISTRANO UNIFIED SCHOOL DISTRICT-CLARENCE LOBO
FACILITY NUMBER: 304270114
VISIT DATE: 11/04/2022
NARRATIVE
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Important COVID-19 resources and links were provided:
· COVID-19 Update Guidance Childcare Programs/Providers link:
https://files.covid19.ca.gov/pdf/guidance-childcare.pdf
· CCLD COVID-19 Licensed childcare and facilities and provider FAQs link: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/child-care-licensing/covid-19-child-care-resources/faqs-for-licensed-child-care-facilities-and-providers
Safe, free, and effective COVID-19 vaccines are now available to everyone age 16 and up. Every Californian can sign up at myturn.ca.gov or call (833) 422-4255 to get their COVID-19 vaccine appointment.

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/process.

Teacher was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

In the areas that were evaluated, four Type B deficiencies were observed of the California Code of Regulations, Title 22, Division 12 at the time of the visit 101174(d)(2), 101212(b), 101212(c), and 101215.1(f).

Exit interview conducted and report was reviewed with Teacher Jessica Ponsen. A notice of site visit was given and must remain posted for 30 days.

Appeal Rights and deficiencies were discussed. Teacher was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days.
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 795-0415
LICENSING EVALUATOR NAME: Dean ThompsonTELEPHONE: (714) 287-0708
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022
LIC809 (FAS) - (06/04)
Page: 4 of 6