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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 561710698
Report Date: 12/20/2019
Date Signed: 12/20/2019 04:57:33 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:HOLY CROSS FAMILY PRE-SCHOOL AND DAY CAREFACILITY NUMBER:
561710698
ADMINISTRATOR:SAMANTHA JULIASFACILITY TYPE:
840
ADDRESS:1212 MARICOPA HIGHWAYTELEPHONE:
(805) 646-8121
CITY:OJAISTATE: CAZIP CODE:
93023
CAPACITY:35CENSUS: 14DATE:
12/20/2019
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Samantha CroceTIME COMPLETED:
05:10 PM
NARRATIVE
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On 12/20/2019, at 2:15 p.m. Licensing Program Analyst, (LPA) Jill Laxo made an unannounced Case Management inspection. The purpose of the inspection was discussed with director Samantha Croce and a tour the facility was conducted. LPA observed 14 school age children outside supervised by two staff.

During the tour director Samantha Croce stated the school age children alternate using the same classroom (purple) as the pre-k children. Pre-k children use the room until 3 p.m. According to the facility sketch, the purple room is for the school age program only.

Type B deficiency is being cited based on LPAs observation and interviews conducted in
accordance with the California Code of Regulations Title 22, See LIC 809D.

An exit interview was conducted with director Samantha Croce and Plans of Correction were
developed. A copy of the appeal rights were provided.


THE NOTICE OF SITE VISIT WAS POSTED
SUPERVISOR'S NAME: Ana TolentinoTELEPHONE: (805) 562-0347
LICENSING EVALUATOR NAME: Jill M Hazelhofer-LaxoTELEPHONE: (805) 635-5097
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2019
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: HOLY CROSS FAMILY PRE-SCHOOL AND DAY CARE
FACILITY NUMBER: 561710698
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/10/2020
Section Cited

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101538.3 Indoor Activity Space for School-Age Children. (b) In combination programs, indoor activity space provided for school-age child care center children shall be physically separated from space provided for infant care and child care center children.
This requirement is not met as evidenced by:
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Based on observation and interviews the
licensee failed to maintain provide a designated specific classroom for the school age program, which poses an Health,potential Health, Safety or Personal Rights risk to the children in care.
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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: Ana TolentinoTELEPHONE: (805) 562-0347
LICENSING EVALUATOR NAME: Jill M Hazelhofer-LaxoTELEPHONE: (805) 635-5097
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2019
LIC809 (FAS) - (06/04)
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