304371449-12-10-2020-06-CC-KDEI-BW6UFP-20201210143302

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304371449
Report Date: 12/10/2020
Date Signed: 12/10/2020 02:33:15 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:	SAUSD JOHN MUIR FUNDAMENTAL-HEAD START		FACILITY NUMBER:	304371449
ADMINISTRATOR:	ERVIN, CHARLOTTE S.		FACILITY TYPE:	850
ADDRESS:	1951 NORTH MABURY STREET		TELEPHONE:	(714) 480-5322
CITY:	SANTA ANA	STATE: CA	ZIP CODE:	92705
CAPACITY:	40	CENSUS: 0	DATE:	12/10/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Adminsitrator Ms. Ervin Charlotte and Early Education Specialist Ms. Rasmussen Judy		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	Licensing Program Analyst (LPA) Ketki Desai conducted an on site pre-licensing inspection at this proposed Head start childcare center. LPA met with, Administrator Ms. Ervin Charlotte and Ms. Rasmussen Judy Early Learning Specialist who gave a tour of the site. The applicant has requested to provide care and supervision for 40 Pre-school age children 3 to 5 years of age, Monday through Friday, 8.00 a.m. to 4.00 p.m. in the two assigned classrooms (Room # 107 and 112) on the campus of John Muir Elementary school site. The school is under Santa Ana Unified School District and school calendar shall be followed through the year. Currently the campus is closed, and classes are held virtually. A review of the Facility Personnel Report Summary on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions through Santa Ana Unified School District. The children shall have access through the designated entrance of the school campus, in front of the main parking lot, upon entering parents shall walk the ramp and on the left side there is a metal gate, which leads to the Head start program, parents shall drop off and pick up the children at this gate during operating hours of the day. Parents shall sign in at the entrance gate upon arrival. Once the school opens the door is locked and later the parents would have to come in through the school reception office area. Due to current Pandemic situation, all COVID guidelines are being implemented. Upon entering temperatures will be checked, hands shall be sanitized before they are taken to the classrooms, Visitors are not allowed at this time. (Page -1)

SUPERVISOR'S NAME: Thuy Ho	TELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki Desai	TELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2020

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 6

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 JOHN MUIR FUNDAMENTAL-HEAD START	FACILITY NUMBER: 304371449
	VISIT DATE: 12/10/2020

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
26
27
28
29
30
31
32

This facility plans to provide Incidental Medical Services – IMS. For IMS information, see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. A Plan of Operation that includes IMS must be submitted to the Department. 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

Incidental Medication will be stored in the classroom in a locked cabinet and shall be administered by the teacher. Medication administration forms were reviewed. There are Program Nurses on site. They provide additional training's to the teachers for administration of medication and treatment. Isolation area is the Nurse’s office on the school complex.

The following were inspected in the indoor activity space:
· Classroom are adequately equipped with age and size appropriate furniture and equipment
· Drinking water is available inside through water fountain as well as Brita water dispenser
· Sign in/Sign out procedure was reviewed and meets regulation requirements (manual sign in and out)
· There is a working smoke detector, carbon monoxide detector and fire extinguisher that meet statutory requirements
· Cubbies available for storage of individual child’s personal belongings
· Room 107 is assigned to a full day program, while room 112 will have two half day sessions.
· Children do not nap in full day and Half day program.
(Page-2)

SUPERVISOR'S NAME: Thuy Ho	TELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki Desai	TELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2020

LIC809 (FAS) - (06/04)

Page: 5 of 6

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 JOHN MUIR FUNDAMENTAL-HEAD START	FACILITY NUMBER: 304371449
	VISIT DATE: 12/10/2020

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
26
27
28
29
30
31
32

Food Services: Children enrolled in full day session shall receive Breakfast / Lunch and PM snack and children in part day AM session shall be served with AM snack with Lunch and PM part day session shall have Lunch and PM snack, upon ending and beginning of their part day sessions.

LPA discussed the posting requirements including, but limited to, the following:
· Facility License in public area (101160)
· Emergency Disaster Plan (LIC 610)
· Earthquake Preparedness Check List (LIC 9148)
· Parents’ Rights Poster (PUB 393)
· Personal Rights (LIC 613A)
· Menus
· Activity Schedule
· Notice of Site Visit (LIC 9213) and Type A deficiencies
· Plan of Corrections of Type A deficiencies
· Child Car Seat Law (PUB 269)

The indoor activity space was measured and is as follows:
Room # 107: 31’33” X 31’33” = 981’57”- 21’45” divided by 35 = 960’12” = 27’43” (27 children)
Room # 112: 25’17” X 24’08” = 660’09” divided by 35= 17’31” (17 children)

Total: 1566’21” divided by 35 = 44’75 (45 children)

5 sinks = 75 children
5 toilets= 75 children

Fire clearance approved the requested capacity of 40 children (Page-3)

SUPERVISOR'S NAME: Thuy Ho	TELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki Desai	TELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2020

LIC809 (FAS) - (06/04)

Page: 6 of 6

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 JOHN MUIR FUNDAMENTAL-HEAD START	FACILITY NUMBER: 304371449
	VISIT DATE: 12/10/2020

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
26
27
28
29
30
31
32

Classroom has two sinks and two toilets in room # 112 and Room # 107 has 1 sink inside the room and two additional sinks and three toilets just outside the room designated to the Head start program. Toilets were observed to have designated signs posted for the Head start program use only.

The following were inspected in the outdoor activity space;
· Playground is fully enclosed by an appropriate fencing
· Drinking water is available outdoors by Water fountain and Water pitchers with sippy cups
· Outdoor activity space is supplied with age and size appropriate equipment, including climbing play structures and outdoor scooters
· An adequate amount of cushioning material consisting of rubber form is in place under the play structures
· Adequate shade is provided by covered patio surrounding the yard.

Outdoor yard shall be used only by Head start program children
Outdoor space: 103’58” X 56 = 5800’48” divided by 75 = 77.34 (77 children)

LPA discussed with the applicant that all employees must have criminal record clearances associated to the facility prior to their presence in the facility, staff to child ratio requirements, direct visual supervision requirements, emergency/disaster drills, children records, mandated reporter training, and staff immunization requirements against measles, pertussis, and influenza.

The applicant was given a pamphlet on Lead Exposure and was discussed with provider. Also provided was information about the E-Learning Modules available at https://ccld.childcarevideos.org. The Chaptered Legislation for AB 2084 (Nutritious Beverages) is available to view on the website at: http://ccld.ca.gov/res/pdf/12APX-11.pdf. (Page-4)

SUPERVISOR'S NAME: Thuy Ho	TELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki Desai	TELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2020

LIC809 (FAS) - (06/04)

Page: 3 of 6

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 JOHN MUIR FUNDAMENTAL-HEAD START	FACILITY NUMBER: 304371449
	VISIT DATE: 12/10/2020

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
26
27
28
29
30
31
32

Applicant/facility representative was informed of Mandated Reporter Training for self and all assistants. Department web site form was given to download forms, Title 22 regulations, and trainings on-line at www.ccld.ca.gov. The applicant/facility representative was also informed to visit the website for Quarterly Updates. The applicant was advised on how to receive notifications for quarterly updates and provided with Child Care Advocate contact information: childcareadvocatesprogram@dss.ca.gov. or at www.ccld.ca.gov

Information on the additional nutrition training, immunization requirements for children, and Health Schools Act (http://www.cdpr.ca.gov/docs/pestmgt/schoolipm.htm) were provided. The applicant/facility representative was informed, and website given, about the California Child Care Disaster Plan has been posted to the UCSF California Childcare Health Program website: cchp.ucsf.edu/content/disaster-preparedness

The facility was in compliance with Title 22 requirements at the time of the inspection.

Based on today's measurements, facility has enough space for the requested capacity of 40 preschool children in two rooms (107 and 112) serving ages 3 years old to 5 years. Monday to Friday 8.00 am to 4.00 PM.

Orange county Fire Authority has granted the Fire clearance for the requested capacity of 40 children.

Administrator Ms. Ervin, Charlotte have completed the new Health and Safety Lead poisoning component training and facility has submitted the water testing results to the LPA.

(Page-5)

SUPERVISOR'S NAME: Thuy Ho	TELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki Desai	TELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2020

LIC809 (FAS) - (06/04)

Page: 2 of 6

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 JOHN MUIR FUNDAMENTAL-HEAD START	FACILITY NUMBER: 304371449
	VISIT DATE: 12/10/2020

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
26
27
28
29
30
31
32

Applicant was also advised, once licensed, the Notice of Site Visit must be posted for 30 days and if A violations are cited then the Licensing Report (LIC809 or 9099) must be posted by the Notice of Site Visit for a period of 30 days or $100 civil penalties will be assessed, and the report shall posted and copies provided to the 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.

In addition, the licensee shall immediately post upon receipt the Proof of Correction for 30 consecutive days and provide a copy to current and enrolling parents. The licensee is to keep Acknowledgement Receipt (LIC 9224) signed by parents in each child’s file

An exit interview was completed with the Administrator Ms. Ervin Charlotte and Ms. Judy Rasmussen Early Learning Specialist.

The report was reviewed and discussed. Appeal Rights were discussed.

The applicant 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

SUPERVISOR'S NAME: Thuy Ho	TELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Ketki Desai	TELEPHONE: (714) 743-8635
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2020

LIC809 (FAS) - (06/04)

Page: 4 of 6