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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372006368
Report Date: 12/05/2019
Date Signed: 12/05/2019 03:14:21 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:ST. MARY, STAR OF THE SEA PRESCHOOLFACILITY NUMBER:
372006368
ADMINISTRATOR:JORDAN JACKSONFACILITY TYPE:
850
ADDRESS:515 WISCONSIN AVENUETELEPHONE:
(760) 722-7475
CITY:OCEANSIDESTATE: CAZIP CODE:
92054
CAPACITY:40CENSUS: 32DATE:
12/05/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:19 PM
MET WITH:Jordan JacksonTIME COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA) Otsanya Cameron made an unannounced visit to the facility and met with Director Jordan Jackson. LPA took census and conducted a physical plan inspection, A case management visit was conducted in response to the receipt of an unusual incident report (UIR) from the facility. The UIR was received by the licensing agency on November 20th, 2019. It indicated ,on November18th, 2019, a child was outside playing on the playground and sustained a cut by eye requiring stitches .

Facility records were reviewed, the Director, 3 Teachers, were interviewed on this date. Based on information gathered, and the LPA's inspection of the backyard play area, there were not any safety hazards present and the facility acted appropriately. No violations have been identified at this time.


An exit interview was held with the Director - Jordan Jackson. A Notice of Site visit was issued, along with a copy of this report which shall be public record for three years.
SUPERVISOR'S NAME: Dawn ParkerTELEPHONE: (951) 320-2101
LICENSING EVALUATOR NAME: Otsanya CameronTELEPHONE: (951) 970-1388
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2019
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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