401710988-9-18-2019-17-CC-GRES-BG5LKW-20190918085010

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 401710988
Report Date: 09/17/2019
Date Signed: 09/18/2019 08:50:17 AM

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:	CAPSLO - FIVE CITIES HEAD START		FACILITY NUMBER:	401710988
ADMINISTRATOR:	D WELCH/ M OROZCO		FACILITY TYPE:	850
ADDRESS:	1800 WILMAR STREET		TELEPHONE:	(805) 473-1657
CITY:	OCEANO	STATE: CA	ZIP CODE:	93445
CAPACITY:	43	CENSUS: 28	DATE:	09/17/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Maria Orozco		TIME COMPLETED:	02:00 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) Gigi Reyes conducted an unannounced annual/random and met with Site Supervisor, Ms. Maria Orozco. There were 28 children present. The center utilizes two classrooms, Room A and B. The center operates from May to August 8:30 AM to 3:00 PM (Room A) 7:45AM to 4:45PM (Room B). The center was toured inside and out. LPA observed as follows: Classrooms are equipped with age and size appropriate furniture and equipment. Water jug with dispenser supplies the drinking water fo indoor and outdoor space. Playground is enclosed with an appropriate fence. An adequate amount of bark cushioning is in place under play equipment. Sign in/sign out record was reviewed and matched the physical count. Carbon monoxide was tested and found functional. Menus and required licensing forms are posted in the prominent location. First Aid kit is found complete. Fire and Disaster drill is conducted and logged every month. A review of staff records and children's records were conducted. CPR and first Aide expires on 1/23/2021. Review of staff records indicates that all staff have criminal record clearance. Site Supervisor and Teachers and staff have met the SB 792 requirements. Staff have taken the AB 1207 Mandated Reporter Training. Effects of Lead Exposure was discussed. The flyer has been distributed to parents of day care children. Continued on 809 C

SUPERVISOR'S NAME: Maria Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi Reyes	TELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2019

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: CAPSLO - FIVE CITIES HEAD START	FACILITY NUMBER: 401710988
	VISIT DATE: 09/17/2019

NARRATIVE

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This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226.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

No deficiencies cited under Title 22 Division 12

LPA observed Site Supervisor posted the Notice of Site Visit.

SUPERVISOR'S NAME: Maria Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi Reyes	TELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2019

LIC809 (FAS) - (06/04)

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