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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304370183
Report Date: 02/08/2022
Date Signed: 02/08/2022 01:05:51 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:NMUSD POMONA PRESCHOOLFACILITY NUMBER:
304370183
ADMINISTRATOR:CASEY, HEATHERFACILITY TYPE:
850
ADDRESS:2051 POMONA AVENUETELEPHONE:
9495156645
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY:72CENSUS: 40DATE:
02/08/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Site supervisorTIME COMPLETED:
01:30 PM
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On 2/8/22 Licensing Program Analyst (LPA) Mahnaz (Nancy) Malek conducted a case management of the facility for an incident which was self reported by the facility representative to our office on 2/4/22. The Covid-19 Emergency Response questionnaire was answered. LPA met with site supervisor, Heather Casey in P1 who were with 14 preschool children and one other staff. There were 13 children in P2 with two staff and there were 13 children with two staff in Room 11. LPA met with Early Childhood Coordinator, Michelle O 'Neill who arrived during LPA's inspection.

A review of staff records on this date indicated that all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions. (The employees are exempt from fingerprinting since they are employed by Newport Mesa Unified School District.

Today LPA interviewed six staff and 6 children regarding the reported incident.
LPA needs more time to review the reported incident based on the lack of information. Final report will be submitted on the next visit.

Appeal Rights were discussed and given to the facility representative A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Michelle O' Niell.





SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Mahnaz MalekTELEPHONE: (714) 292-9851
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2022
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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