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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304270940
Report Date: 11/07/2023
Date Signed: 11/07/2023 04:08:33 PM


Document Has Been Signed on 11/07/2023 04:08 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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868



FACILITY NAME:LAGUNA NIGUEL ELEMENTRY-SOUTH COAST YMCAFACILITY NUMBER:
304270940
ADMINISTRATOR:ERFAAN REZAIENIAFACILITY TYPE:
840
ADDRESS:27922 NIGUEL HEIGHTS BLVD.TELEPHONE:
(949) 215-2030
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY:88CENSUS: 57DATE:
11/07/2023
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:DirectorTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA), Mahnaz (Nancy) Malek conducted an onsite inspection for the purpose of an Annual Required inspection. LPA met with director Erfan Rezaienia who was checking children in. LPA also met with Executive Director, Pam Kowalski. LPA toured the facility inside and outside. (Rooms 27 & 28).
The floor and yard plan (LIC 999) were checked. LPA took census, there were a total of 57 school age children with 6 staff. During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staffing ratios. Facility hours are 6:45 a.m.- 6:00 p.m., Monday through Friday on School Holidays and before and after school.
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, items which could pose a danger to children (cleaning compounds, and medications) were observed to be stored out of the reach of children. Poisons/Hazardous Items are not kept on the premises. The facility provides morning, afternoon snacks and lunch is provided by parents on full days attendance. Floors, equipment, and furniture were clean and were observed to be in good repair and free of sharp edges. Drinking water is available to children indoors by water containers that children bring from home and the facility fill them up with filtered water.
The facility has conducted an emergency drill within the past six months, last drill was in 11/1/2023.
The facility has a working carbon monoxide detector and fire extinguisher. Facility met all posting requirement.

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SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 703-2741
LICENSING EVALUATOR NAME: Mahnaz MalekTELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2023
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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: LAGUNA NIGUEL ELEMENTRY-SOUTH COAST YMCA
FACILITY NUMBER: 304270940
VISIT DATE: 11/07/2023
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The outdoor activity space was inspected for compliance. The school outdoor space 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 cushioning material around the climbing equipment such as slides appeared to be enough to absorb falls. Drinking water in the outdoor activity space is provided by water containers children brought from home and the facility fills them up by filtered water if needed. 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 YMCA Program used the elementary school playground for children which is located on Laguna Niguel Elementary School.
Staff files were reviewed for staff present during the facility inspection on this date, 6 staff files were reviewed. Health screening and immunization 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 staff were reviewed and all in 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. At least one staff member present possesses current EMSA approved Pediatric CPR/First Aid certifications, which expires 9/10/2024.

Children's records were reviewed, and there was a separate, complete and current record for each child. A random sample of 5 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). In the areas reviewed the children’s files were found to be in full compliance.
Sign in/out procedure was reviewed for compliance. The facility uses electronic sign in out procedure.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care
Centers (CCCs) constructed before January 1, 2010, to test their water (used for
drinking and food preparation) for lead contamination before January 1, 2023, and then every

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SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 703-2741
LICENSING EVALUATOR NAME: Mahnaz MalekTELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: LAGUNA NIGUEL ELEMENTRY-SOUTH COAST YMCA
FACILITY NUMBER: 304270940
VISIT DATE: 11/07/2023
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5-years after the date of the first test. LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP. Facility passed the testing without lead exceedance.

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

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of “medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301(voice) or (800) 514-0383 (TTY) and link to publication. Commonly Asked Questions about Child Care Centers and the ADA are available at:https://www.ada.gov/resources/child-carecenters

The Executive Director, Pamela Kowalski was reminded that all adults 18 and over responsible for administration or direct supervision of staff, persons who provides care and supervision to children, and staff who have contact with children, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms.

To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communications.

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SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 703-2741
LICENSING EVALUATOR NAME: Mahnaz MalekTELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: LAGUNA NIGUEL ELEMENTRY-SOUTH COAST YMCA
FACILITY NUMBER: 304270940
VISIT DATE: 11/07/2023
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The Executive Director, Pamela Kowalski was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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.

A notice of site visit was given to the Executive Director, Pamela Kowalski and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

In the areas that were evaluated, no deficiency was observed of the California Code of Regulations, Title 22, Division 12 on this inspection date.


Exit interview conducted and report was reviewed with the Executive Director, Pamela Kowalski.

End of report.

SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 703-2741
LICENSING EVALUATOR NAME: Mahnaz MalekTELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5