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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304370362
Report Date: 10/30/2019
Date Signed: 10/30/2019 09:30:22 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:NMUSD PAULARINO PRESCHOOLFACILITY NUMBER:
304370362
ADMINISTRATOR:HERNANDEZ, ANAFACILITY TYPE:
850
ADDRESS:1060 PAULARINO AVENUETELEPHONE:
(714) 424-7950
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY:24CENSUS: 22DATE:
10/30/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Michelle OneillTIME COMPLETED:
09:45 AM
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Licensing Program Analyst (LPA) Hawkins made an unannounced visit to the facility for the purpose of conducting an Annual Inspection. LPA met with early childhood coordinator Michelle Oneill and a facility inspection was conducted. Due to emergency needs of the Department the annual inspection will be continued on another date.

Exit interview was conducted. Report read out loud, reviewed and discussed. Notice of Site Visit was posted. The licensee was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. The facility representative was informed that the “Notice of Site Visit” must be posted for 30 consecutive days. Failure to post will result in Civil Penalties of $100.00.
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Sherene HawkinsTELEPHONE: (949) 466-1624
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2019
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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