401710581-12-6-2019-17-CC-EBAY-BJM2Z5-20191206164946

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 401710581
Report Date: 12/06/2019
Date Signed: 12/06/2019 04:50:00 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME:	HAWTHORNE ELEMENTARY SCHOOL		FACILITY NUMBER:	401710581
ADMINISTRATOR:	M. BURGER / RACHEL BALLELA		FACILITY TYPE:	840
ADDRESS:	2125 STORY		TELEPHONE:	(805) 781-7300
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93401
CAPACITY:	55	CENSUS: 23	DATE:	12/06/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Michelle Rolle		TIME COMPLETED:	05:00 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) Elvin Baddley conducted an unannounced Annual/Random inspection of the abovementioned Child Care Center (CCC). LPA met with Michelle Roole, Recreation Coordinator, and Jenna Atiya, Recreation Specialist, and explained the purpose of the inspection. LPA, in the company the Recreation Coordinator and Specialist, toured the interior and exterior of the center. The center services children attending Hawthorne Elementary School and operates from 7:00 AM to 6:00 PM, Monday - Friday. The center uses one classroom for care and had a population of 23 children in care at the time of the inspection. The classroom of the center is clean and organized. The classroom has age appropriate furnishings available for children. The classroom's carbon monoxide detector was tested and found to be inoperable. The Recreation Coordinator was reminded of the necessity to have a functioning carbon monoxide detector on site. The attached restroom is in safe and sanitary operating conditions. The bathroom contains a single toilet and a sink just outside of the restroom. Children also have access to two restroom at the school site. Children are escorted to the restroom by staff member who remain in proximity of the area during use. Disinfectants, cleaning solutions, medication and sharps are secured in an elevated locked cabinets within the classroom. The center provides snacks for the children and the LPA observed a posted menu. Likewise, the classroom has licensing required notices posted predominately on a "Family Board" near the classroom entry/exit. The LPA reviewed the center Sign In/Out forms which were completed appropriately. The center’s outdoor playground area is comprised of a grass lawn, a black top and a wood chip play box the play area is enclosed by chain linked fencing. LPA observed age appropriate furnishing in the play area. CONT. 809-C

SUPERVISOR'S NAME: Maria Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Elvin Baddley	TELEPHONE: (805) 635-4697
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2019

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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: HAWTHORNE ELEMENTARY SCHOOL	FACILITY NUMBER: 401710581
	VISIT DATE: 12/06/2019

NARRATIVE

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The play structure in the play area has adequate cushioning materials (i.e. wood chips) to absorb falls and an abundance of shade (i.e. tress). No bodies of water were observed on site. There is available drinking water for children both inside of the classroom and outside in the play area. Waste receptacles with tight fitting covers were observed throughout the center.

A sampling of staff and children records were reviewed. The children’s records were complete and found to contain emergency contact information as well as medical assessments. Staff records were reviewed and found to be complete. Recreation Coordinator stated no firearms/weapons or ammunition was stored on the premise.

LPA discussed a guide for Safe Sleep and the Effects of Lead Exposure with the Recreation Coordinator. A Safe Sleep leaflet was provided and the center all ready provides the effects of Lead Expose to its parents.

This facility provides Incidental Medical Services (IMS). LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. 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.

Pursuant to Title 22 of the CA Code of Regulations, the following Type B deficiency was cited (refer to LIC 809-D). The Recreation Coordinator was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. The LIC 9213 (Notice of Site visit) was posted during today's visit.

The LIC 9213 (Notice of Site visit) was posted during today's visit.

SUPERVISOR'S NAME: Maria Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Elvin Baddley	TELEPHONE: (805) 635-4697
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2019

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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: HAWTHORNE ELEMENTARY SCHOOL	FACILITY NUMBER: 401710581
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/06/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/09/2019 Section Cited	1 2 3 4 5 6 7	Carbon monoxide detectors required; inspection Every licensed child day care center shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by the following: Based on the observation/interview by the LPA the center failed to provide an operable carbon monoxide detector in the classroom. This poses an potential risk to the health, safety or personal rights of persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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: Maria Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Elvin Baddley	TELEPHONE: (805) 635-4697
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2019

LIC809 (FAS) - (06/04)

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