304370947-6-28-2022-06-CC-KDEI-CFTQCE-20220628120301

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304370947
Report Date: 06/28/2022
Date Signed: 06/28/2022 12:04:08 PM

Document Has Been Signed on 06/28/2022 12:04 PM - It Cannot Be Edited

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:	SAUSD/JACKSON ELEMENTARY		FACILITY NUMBER:	304370947
ADMINISTRATOR:	ORLANDO, KEELY		FACILITY TYPE:	850
ADDRESS:	1143 NAKOMA DRIVE		TELEPHONE:	(714) 569-3536
CITY:	SANTA ANA	STATE: CA	ZIP CODE:	92704
CAPACITY:	60	CENSUS: 0	DATE:	06/28/2022
TYPE OF VISIT:	Case Management - Licensee Initiated	ANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Ms.Berber, Veronica : Early learning Specialist		TIME COMPLETED:	12:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	An announced case management inspection was conducted on this date by Licensing Program Analyst (LPA) Desai, Ketki for the purpose of swapping the three classrooms with a change in capacity (Decrease). The facility is requesting a change in capacity to 48 children. The facility is currently licensed for 60 preschool children in room # 12,13 and 14. Now facility has now requested to swap the three classrooms to Room # 15,16 and 17. Half day session shall be offered in Room # 17 and Full day session in Room # 16 and Room 15 shall be used during napping time only for now. LPA Desai, Ketki met with Early learning Specialist : Ms Berber, Veronica who guided analyst on a tour of the facility. The facility is located on the Andrew Jackson Elementary School campus, there were no children present on the site due to summer break. Currently the facility has two sessions Full day session (8-4pm ) and half day sessions :AM session 8:00-11:00 and PM session from 12 noon to 3.00 PM , Monday- Friday serving children ages 2-5 years old. Facility has a Waiver on file to share the elementary school bathrooms and the kindergarten playground. A review of staff records on this date indicates that all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions. All areas identified on the Facility Sketch were inspected. If children become ill during the day, they will rest in the isolation area located, in the nurse’s office, located in the front of the school away from the other children, there is also a bathroom located in this area for the ill children to use. Medication will be stored in the classroom, located in a top cabinet. (1)

SUPERVISOR'S NAME: Thuy Ho	TELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki Desai	TELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022

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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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: SAUSD/JACKSON ELEMENTARY	FACILITY NUMBER: 304370947
	VISIT DATE: 06/28/2022

NARRATIVE

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Incidental Medical services are provided. Furniture and equipment were inspected for age appropriateness and good repair. Age appropriate sinks and toilets were inspected for availability, good repair, water temperature, toilet paper, paper towels, area safety and sanitation. The facility provide water inside/outside by a water jug and disposal cups and children bring their own water bottles from home labeled with their names. First Aid supplies were inventoried.
Center provides breakfast for the AM session children and lunch for the PM children, which is delivered to the facility by the school district cafeteria. Full day session shall receive Breakfast/Lunch and PM snack.

The new classrooms are behind the main school office, next to the old classrooms
Room #16 is a full day program from 8.00 am to 4.00 PM and children shall be offered: Breakfast/ Lunch and PM snack . Napping will be in Room # 15 for this classroom. Children shall nap on the blue cots, linens and blankets shall be provided by the center and washed by the parents on a weekly basis.
Room # 17: will offer two half day sessions. AM session from 8.00 am to 11.00 am and Breakfast shall be offered while PM Session will be from 12 noon to 3.00 PM. Napping is not offered in the half day session programs.
Following was observed in the new classrooms 15,16 and 17
1) Age appropriate furniture and activities including Educational / Arts & Crafts items.
2) Room is well ventilated with proper lighting and shade.
3) There is a working Smoke detector / Carbon Monoxide detectors and Fire Extinguisher.
4) There are toilets with three sinks in between the two classrooms and additional toilets are present on the school premises.
5) Parent drop off - pick up: Designated front fenced gate on Nakoma Street ,during drop off and pick up time, teachers shall be at the gate to receive and hand over the child. Electronic sign in is done. Program is using Kindersign application .

Preschool rooms were measured today: Indoor activity space: 2366'39 divided by 35 = 67'61 (68 children)
Facility has sufficient space to accommodate 48 preschool age children as requested. Facility at this time is decreasing the capacity.

Total sinks : 13 X 15 = 195 children / Toilets: 16 X 15 = 240 children

Children shall continue to use the same play yard outside the classrooms as before. (2)

SUPERVISOR'S NAME: Thuy Ho	TELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki Desai	TELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022

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: SAUSD/JACKSON ELEMENTARY	FACILITY NUMBER: 304370947
	VISIT DATE: 06/28/2022

NARRATIVE

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Play yard is outside the classroom at the exit doors of the classrooms accessible from each classroom.. Play-yard is completely enclosed. Outdoor activity area is supplied with age and size appropriate equipment with wooden chips as a cushion material and adequate shade is provided by trees.

Fire clearance approval letter on file and dated 06/23/2022, is on file for the new rooms.

In the areas evaluated, no deficiency was observed and cited today per CA Code of Regulations, Title 22, and Division 12.

A new License shall be issued upon management approval

48 Preschool age children (2-5 years) old in Room # 15,16 and 17
Full day session in Room # 16 with napping in Room # 15 (8.00 am to 4.00 PM)
Two sessions AM/PM session in Room # 17 (8.00 am to 11.00 am ) & (12.00 PM to 3.00 PM)

Exit interview was conducted. A copy of this report and appeal rights were discussed and provided to the director. The Notice of Site Visit was posted. The director 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.

SUPERVISOR'S NAME: Thuy Ho	TELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki Desai	TELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022

LIC809 (FAS) - (06/04)

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