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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197414967
Report Date: 06/02/2022
Date Signed: 06/02/2022 02:05:10 PM

Document Has Been Signed on 06/02/2022 02:05 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:CAPISTRANO ELEMENTARY SCHOOL PRESCHOOLFACILITY NUMBER:
197414967
ADMINISTRATOR:GIBBS, ALICEFACILITY TYPE:
850
ADDRESS:8118 CAPISTRANO AVENUE ROOM #1TELEPHONE:
(818) 883-8981
CITY:WEST HILLSSTATE: CAZIP CODE:
91304
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 14DATE:
06/02/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Maribel RamosTIME COMPLETED:
02:00 PM
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On 6/2/22 at 1:00p.m. Licensing Program Analyst (LPA) Doris Whitmore conducted an unannounced Case Management Annual Continuation Inspection. Unannounced inspection was previous conducted 5/27/22. l LPA met with the Office Tech Maribel Ramos. LPA reviewed a sample of 10 children files and observed files were complete with required documents. The 10 files that were reviewed were from the morning class. Per Title 22 Division 22 Chapter 3, of California Code of Regulations there were no deficiencies cited. Notice of Site Visit was provided and required to be posted for 30 days.
SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Doris Whitmore
LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2022
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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