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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406214424
Report Date: 06/03/2022
Date Signed: 06/03/2022 02:47:19 PM


Document Has Been Signed on 06/03/2022 02:47 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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117



FACILITY NAME:CAPSLO-NIPOMO HEAD STARTFACILITY NUMBER:
406214424
ADMINISTRATOR:A. RAMIREZ-BARRONFACILITY TYPE:
850
ADDRESS:291 THOMPSON ROADTELEPHONE:
(805) 544-4355
CITY:NIPOMOSTATE: CAZIP CODE:
93444
CAPACITY:30CENSUS: 18DATE:
06/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Socorro CanoTIME COMPLETED:
02:50 PM
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On June 3, 2022, at 11:35 AM, Licensing Program Analyst (LPA) GIgi Reyes conducted an unannounced Required 1- Year Inspection and met with Site Supervisors, Socorro Cano. LPA asked pre screening questions related to COVID -19 and Site Supervisor responses indicates there are no COVID 19 exposures on site. LPA discussed the purpose of the inspection. There were 18 children and and 5 staff present during the inspection.

LPA in the company of Site Supervisor toured the Child Care Center (CCC) inside and out. LPA observed Licensing required forms are posted by the entrance door. The classroom is equipped with age appropriate games, activities, and furniture available for children in care. LPA observed and reviewed the posted menu. The center provides breakfast, lunch and snack. CCC is clean and in order. Hazardous items are stored inaccessible to children in care. Water dispenser supples drinking water inside the classroom. Water jug dispenser supplies the drinking water in the play yard. The outdoor playground is completely fenced with age appropriate toys and equipment. The playground has an ample amount of shade available and cushioning under the play equipment.

CCC uses the manual sign in/sign out. A sampling of children and staff records were reviewed. Teachers have required qualifications. Teachers present have current Pediatric First Aid/CPR certificates that expire 1/6/2023. Teachers have proof required immunization per SB 792. CCC is implementing the COVID 19 Guidelines. CCC conducts fire and disaster drill every month, last drill was conducted on May 20, 2022.

During today's inspection, no deficiencies were cited.
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi ReyesTELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:
DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2022
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: CAPSLO-NIPOMO HEAD START
FACILITY NUMBER: 406214424
VISIT DATE: 06/03/2022
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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

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Site Supervisors were 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 Site Supervisor, Socorro Cano.
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi ReyesTELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2022
LIC809 (FAS) - (06/04)
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