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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304370847
Report Date: 07/24/2019
Date Signed: 07/24/2019 03:38:43 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:
07/24/2019
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Ashley Neitzke TIME COMPLETED:
01:30 PM
NARRATIVE
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A case management inspection was made today by Licensing Program Analyst (LPA) Connolly. The LPA met with director Ashley Neitzke who accompanied the LPA on a tour of the infant center. There were 8 infants in care with two attending staff.
A review of staff records on this date indicates that not all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Staff Stephanie Bejar does not have child care criminal record clearances. According to the director Stephanie Bejar has been working in the infant center since May 2019.
In the areas that were evaluated the facility was not in compliance and violation of the California Code of Regulations, Title 22, Division 12 was observed, discussed and cited at the time of the inspection. Based on LPAs observations and record review the following violation was observed and is being cited in accordance with California Code of Regulations, Title 22, Division 12, Section 101170(e)(1).
Violation is being cited on the attached LIC 809D.

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. If the facility receives a Type 'A' violation the director shall post and provide copies of the report to parents/guardians of the children in care at the facility by the next business day and shall provide to the parents/guardians of children newly enrolled at the facility during the next 12 months. The licensee is to keep Acknowledgement Receipt (LIC9224) signed by parents in each child’s file. 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. The ‘Notice of Site Visit’ must be posted on or adjacent to the door. Failure to post A Reports for 30 days will result in a civil penalty of $100.00.
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Gesine ConnollyTELEPHONE: (714) 703-2822
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2019
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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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: 07/24/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/24/2019
Section Cited
CCR
101170(e)(1)
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All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:
Obtain a California clearance or a criminal record exemption as required by the Department
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Director acknowledged that staff without child care criminal record clearances cannot work, cannot be present at the facility until child care criminal record clearances are associated to the day care.
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This regulation is not met per LPA's observation of staff, Stephanie Bejar, providing care and supervision in the infant center and a record review which confirmed Stephanie Bejar does not have child care criminal record clearances. This poses an immediate risk to the 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: 07/24/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2019
LIC809 (FAS) - (06/04)
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