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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304370150
Report Date: 12/23/2020
Date Signed: 12/23/2020 02:58:20 PM

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:NOBIS PRESCHOOLFACILITY NUMBER:
304370150
ADMINISTRATOR:CLARK, ELENAFACILITY TYPE:
830
ADDRESS:190 EAST 15TH STREETTELEPHONE:
(949) 548-2550
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY:16CENSUS: 14DATE:
12/23/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Kenya MenesesTIME COMPLETED:
11:05 AM
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Tele-Inspection

Licensing Program Analyst (LPA) Hawkins conducted an unannounced Case Management Tele-visit via Facetime with Acting Director Kenya Meneses to follow up on an unusual incident reported to the Licensing office on 12/18/20. LPA notified the Director that due to Covid-19 and Department of Public Health (DPH) guidelines of social distancing a tele-visit was required. Director provided an alternate number to conduct the tele-visit. A virtual tour was conducted by the director and present were 14 children (8 toddlers, 6 infants) and 5 infant/toddler staff including the director. A review of staff and other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.

During this tele-visit LPA Hawkins discussed the incident reported of law enforcement conducting an inspection and investigation at the facility. Acting director explained that the Costa Mesa Police Department did conduct a walk through of the infant program and after there inspection and interview of staff, director was informed that no further action would be taken and law enforcement provided an incident #20-016699.

LPA was provided the responding police department agency phone number 714-754-5280 and fax number 714-754-5124 to retrieve reports. The responding officer was Brian Glass and he reported to the facility that a previous employee reported that staff was applying pressure on the infants back while assisting them at nap time.

No deficiencies were cited for this case management inspection Further information will be gathered and a follow up inspection will be conducted. .

***continued on page 2***
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Sherene HawkinsTELEPHONE: (949) 466-1624
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2020
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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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: NOBIS PRESCHOOL
FACILITY NUMBER: 304370150
VISIT DATE: 12/23/2020
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An exit interview was conducted with Director via Tele-Inspection. A copy of the report along with Appeal Rights will be emailed to the Director with a Read Receipt to acknowledge report was received. Director will respond to email stating “I have read and received the report, I acknowledge receipt.” If Read Receipt is not available, LIC 809 will also be mailed if those options are not available. End of Report.

SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Sherene HawkinsTELEPHONE: (949) 466-1624
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2020
LIC809 (FAS) - (06/04)
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