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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304370847
Report Date: 05/01/2019
Date Signed: 05/01/2019 03:20:35 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:
304370847
ADMINISTRATOR:NEITZKE, ASHLEYFACILITY TYPE:
830
ADDRESS:26153 VICTORIA BLVD.TELEPHONE:
(949) 661-6258
CITY:CAPISTRANO BEACHSTATE: CAZIP CODE:
92624
CAPACITY:16CENSUS: 4DATE:
05/01/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Ashley Neitzke TIME COMPLETED:
03:15 PM
NARRATIVE
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An annual inspection was conducted at the facility by Licensing Program Analyst (LPA) Connolly The facility file was reviewed prior to this inspection. Upon arrival the LPA met with director Ashley Neitzke who accompanied on a tour of the facility. Census was taken. At the time of the LPA arrival there were four infants in care with one attending staff. The infants were in the designated infant activity space. The facility is operating within its licensed capacity and within compliance of staffing ratios. A review of the personnel report on file indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances.

Operating hours are Monday through Friday 7:00 AM to 6:00 PM. The items which could pose a danger to children (detergents, cleaning compounds ) were stored inaccessible to infants in care. Poisons/hazardous items are not located in the infant area. The toys, floors and other equipment appeared clean, safe and age appropriate for infants. There is sufficient napping equipment. Exposed foam was observed on crib mattresses. Infants currently in care are not using these mattresses. Bedding is being laundered at home on a weekly basis and as needed. . There is a waiver in that changing tables are within hand sanitizing equipment. Food is properly stored. Bottles and food containers brought from home are properly labeled with name and date.

There is a working smoke detector, carbon monoxide detector and fire extinguisher in the infant center. At least one staff member present possessed current CPR/First Aid certifications, which expire 8/2019. The director provided a copy of the documented practised disaster drills within the last six months.

The playground is completely fenced. The playground equipment appeared in safe condition. There is sufficient cushioning underneath climbing structures and/or play equipment. shade is provided.

Continued on page two
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Gesine ConnollyTELEPHONE: (714) 703-2822
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
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: 304370847
VISIT DATE: 05/01/2019
NARRATIVE
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Page Two
Children and staff records were reviewed and are within compliance. Proof of immunization against pertussis, influenza (or written declination), and measles for all employees/volunteers were reviewed and found in compliance with SB 792. Mandated Reporter Training Certificates were in each staff file. Infant Needs and Services/Feeding Plans were reviewed and found in compliance. The sign in/out procedure was reviewed.

During today’s inspection the LPA discussed incidental medical services with the director. The director said there are no incidental medical services being provided at this time. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. 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.

The director provided an updated Personnel Report (LIC 500) and updated Designation of Facility Responsibility (LIC 308) and a copy of the waiver issued to use hand sanitizers in lieu of soap and water because the infant changing table is not within arm's reach of a sink. This waiver was readily available.

In the areas that were evaluated the facility was not in compliance and one violation of the California Code of Regulations, Title 22, Division 12 was observed and cited at the time of the inspection.

An exit interview was completed. The report was reviewed and discussed. Appeal Rights were discussed. The facility representative was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the licensing office within 15 business days.

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 penalty of $100.00. The 'Notice of Site Visit' ' must be posted on or adjacent to the door.

All licensing reports are public information and must be made available upon request.
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Gesine ConnollyTELEPHONE: (714) 703-2822
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2019
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: 304370847
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/01/2019
Section Cited
CCR
101439.1(4)(c)
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101439.1(4)(c) Infant Care Center Napping Equipment: Crib mattresses shall be maintained in a safe condition with no exposed foam, batting or coils. This regulation is not met as evidenced by a tour of the infant center when LPA observed mattresses with exposed yellow foam.
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The director said new mattresses will be ordered today and the mattresses with exposed foam will be discarded today.
The director said a picture of the new mattresses with matching tight fitting sheets will be emailed to the licensing office.
LPA provided email address.
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These mattresses were not in use by infants in care. The presence of crib mattresses with exposed foam poses a potential risk to the health and safety of children in care.
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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) 703-2807
LICENSING EVALUATOR NAME: Gesine ConnollyTELEPHONE: (714) 703-2822
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2019
LIC809 (FAS) - (06/04)
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