<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364809555
Report Date: 05/03/2023
Date Signed: 05/06/2023 06:03:31 PM


Document Has Been Signed on 05/06/2023 06:03 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551



FACILITY NAME:SBCSS GENERAL COLIN L. POWELL STATE PRESCHOOLFACILITY NUMBER:
364809555
ADMINISTRATOR:NANCY ALVARADOFACILITY TYPE:
850
ADDRESS:37041 RHINELAND DRIVETELEPHONE:
(760) 386-7940
CITY:FT. IRWINSTATE: CAZIP CODE:
92310
CAPACITY:192CENSUS: 56DATE:
05/03/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:39 AM
MET WITH:Doris Paulino TIME COMPLETED:
01:40 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
On 05/03/23 at 10:14 a.m. Licensing Program Analysts (LPA) Esequiel Rodriguez conducted an unannounced Annual Required inspection at the SBCSS General Colin L. Powell State Preschool Center Facility to continue to assess the Center's operation of their Program. Also, to evaluate the Center's continuing ability to meet compliance with California Code of Regulations (CCR) Title 22, Health and Safety requirements, and other applicable State and Licensing Statutory requirements. The LPA met with the alternate Site Supervisor, Doris Paulino and stated the purpose for the inspection.

During the previous inspection the LPA only inspected the Physical Plant in which the entire physical plant met regulatory requirements. See LIC 809 report dated 04/28/23 for more.

The facility is licensed to provide child care services and education to, up to, 192 ambulatory children ages two to nine years old. The Center Supervisor indicated the teachers/staff ensure the facility does not go over the capacity specified on the license.

The LPA conducted a review of several Staff records. The review included, but was not limited to the following: Criminal record statements (LIC 508) Record of submission of Child Abuse Index Checks. Staff qualification. Reference letters and verifying work experience on file. Health clearances, including TB clearances. Pediatric CPR/first aid cards for designated staff. 15 hours of health & safety training for designated Staff. Notice of Employee Rights receipts (LIC 9052). Statement Acknowledging Requirement to Report Suspected Child Abuse. (LIC 9108) and Mandated Reporter Training certificate. Copy of driver’s license. Personnel Record (LIC 501) or application/resume with required information.



A review of staff records on today's date indicates that the Center staff and other individuals listed on the LIC 500, Personnel Report and other personnel working at the Facility have received Criminal Record, FBI,
SUPERVISOR'S NAME: Scott HerringTELEPHONE: (661) 202-3314
LICENSING EVALUATOR NAME: Esequiel RodriguezTELEPHONE: (661) 202-3321
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2023
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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: SBCSS GENERAL COLIN L. POWELL STATE PRESCHOOL
FACILITY NUMBER: 364809555
VISIT DATE: 05/03/2023
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
Pg-2
DOJ. and Child Abuse Central Index Check clearances or exemptions.

Also, a review of several Children records was conducted. The review included, but was not limited to the following: Admission agreements. Needs and Services Plans for infants,. Immunization Records (“blue cards; PM 286) for non-school-age children. Authorizations for dispensing medications signed by parents. Identification and Emergency Information forms (LIC 700) Child’s Pre-admission Health History- Parents’ Report forms (LIC 702) Child’s Pre-admission Health Evaluations- Physician’s Report forms (LIC 701)
Documentation required for health-related services (e.g., blood-glucose monitoring, nebulizer care LIC 9166, gastrostomy-tube care LIC 701A and LIC 701B) Consent for Emergency Medical Treatment forms (LIC 627) Unusual Incident/Injury or Death Reports (LIC 624) Parents’ Rights (LIC 995) receipts, signed and dated. Personal Rights receipts (LIC 613), signed and dated.

At the time of the inspection, the LPA observed appropriate Staffing Ratio and Capacity: Staffing ratios per number of children in care was in compliance.

Per Center Supervisor and Staff interviewed all children in care are accorded with their Personal Rights. Each child in the facility receiving services is treated with dignity and respect and have certain rights that will never be waived or abridged by anyone providing services in the facility regardless of consent or authorization from the child's authorized representative.

The Center Supervisor and staff are aware of Title 22 Reporting Requirements in accordance with Title 22 (101212) including to notify the Department in writing of his/her intent prior to making any structural changes that reduce the total amount of indoor or outdoor activity space. Such structural changes shall include, but not be limited to any physical plant addition.

The LPA advise the Facility Supervisor to become very familiar with the Guardian Background Check Program and Title 22, California Code of Regulations. The LPA provided information regarding where to locate Information Provider Notices (PINs) Training (e.g. Mandated Reporter) and how to access and subscribe to Child Care Licensing Quarterly Updates.
SUPERVISOR'S NAME: Scott HerringTELEPHONE: (661) 202-3314
LICENSING EVALUATOR NAME: Esequiel RodriguezTELEPHONE: (661) 202-3321
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: SBCSS GENERAL COLIN L. POWELL STATE PRESCHOOL
FACILITY NUMBER: 364809555
VISIT DATE: 05/03/2023
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
Pg-3
During today's inspection the LPA observed no deficiencies that may hinder the health and safety of the children in care.

Overall, the Center is in compliance per Title 22 regulations. Therefore, no deficiencies cited during this inspection.

The LPA and Site Supervisor went over this report and an exit Interview was conducted and a copy of this Report, Children's Record Review form, LIC 857, Review of Staff Records form, LIC 859, Notice of Site Visit, LIC 9213 were provided to Ms. Paulino.
SUPERVISOR'S NAME: Scott HerringTELEPHONE: (661) 202-3314
LICENSING EVALUATOR NAME: Esequiel RodriguezTELEPHONE: (661) 202-3321
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3