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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 401710581
Report Date: 09/15/2022
Date Signed: 09/15/2022 10:24:46 AM


Document Has Been Signed on 09/15/2022 10:24 AM - 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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117



FACILITY NAME:HAWTHORNE ELEMENTARY SCHOOLFACILITY NUMBER:
401710581
ADMINISTRATOR:MICHELLE ROLLEFACILITY TYPE:
840
ADDRESS:2125 STORYTELEPHONE:
(805) 781-7447
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY:55CENSUS: 11DATE:
09/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Michelle RolleTIME COMPLETED:
10:15 AM
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On 9/15/22, at 8:30 AM, Licensing Program Analyst (LPA) Elvin Baddley conducted an unannounced One Year Required Inspection of the abovementioned Child Care Center (CCC). LPA met with Administrator Michelle Rolle and explained the purpose of the inspection. LPA, in the company the Administrator toured the interior and exterior of the CCC. The CCC operates on the grounds of Hawthorne Elementary School from 7:00 AM to 6:00 PM, Monday - Friday. The two programs at the CCC run form 7:00 AM -8:15 AM (AM Program) and 2:40 PM - 6:00 PM (PM Program). The CCC uses one classroom for care. LPA observed 11 children on site along with 2 teachers (cleared and associated) providing care and supervision.

The classroom of the CCC is clean and organized. The classroom has age appropriate furnishings available for children. LPA observed a carbon monoxide detector near the entry of the CCC which was tested at 9:45 AM and found to be operable. The attached restroom is in safe and sanitary operating conditions. The restroom 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 members who remain in proximity of the restroom area during use. Disinfectants, cleaning solutions, sharps and medication are stored on elevated shelves in a locked cabinet. The cabinet is inaccessible to children in care.

The CCC provides a mid snacks for children,. LPA notes the CCC is not in session during the lunch hours. Children have access to water both inside of the classroom and outside in the activity area. LPA reminded Administrator of the need to test the CCC's water sources for lead containments. LPA observed a posted menu near the entry of the CCC. Likewise, the classroom has licensing required notices posted predominately near the teacher's desk. LPA reviewed the CCC's Sign In/Out forms which contained the children's arrival and departure times as well as the signature of authorized representatives.

The CCC's outdoor playground area is comprised of various surfaces and is enclosed by chain linked fencing.
(CONT. LIC 809-C)
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Elvin BaddleyTELEPHONE: (805) 635-4697
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022
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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: HAWTHORNE ELEMENTARY SCHOOL
FACILITY NUMBER: 401710581
VISIT DATE: 09/15/2022
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LPA observed age appropriate furnishing in the area. The play structure in the playground area has adequate cushioning materials to absorb falls and an abundance of shade created by trees and building overhangs. No bodies of water are observed on site. LPA observed waste receptacles with tight fitting covers throughout the CCC.

Staff and children's records were reviewed. The children’s records were complete and found to contain emergency contact information. Staff records were reviewed and contained current pediatric CPR and First Aid certifications (EMSA approved) along with Mandated Reporter certifications. Administrator is reminded to to ensure training certifications are current and renewed prior to expirations. Administrator informed LPA no firearm or ammunition is stored on site.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated 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

Facility representative was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Facility representative Michelle Rolle.

SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Elvin BaddleyTELEPHONE: (805) 635-4697
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022
LIC809 (FAS) - (06/04)
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