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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304270605
Report Date: 02/07/2022
Date Signed: 02/07/2022 02:57:01 PM

Document Has Been Signed on 02/07/2022 02:57 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:MARINERS CHURCH PRESCHOOLFACILITY NUMBER:
304270605
ADMINISTRATOR:SCIABICA, LISAFACILITY TYPE:
850
ADDRESS:5001 NEWPORT COAST DRIVETELEPHONE:
(949) 769-8261
CITY:IRVINESTATE: CAZIP CODE:
92612
CAPACITY: 194TOTAL ENROLLED CHILDREN: 194CENSUS: 100DATE:
02/07/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Amanda Wilson, Lead TeacherTIME COMPLETED:
12:00 PM
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Licensing Program Analyst(LPA) P Rivas conducted an unannounced case management visit to investigate two incidents reported on 02/02/22.

A review of staff records indicates all facility staff or individuals who require caregiver background checks have received a criminal record clearances or exemptions and a child abuse index clearance. A Facility Risk assessment was conducted to determine the level of Personal Protective Equipment (PPE) was needed for an on-site inspection.
Due to COVID 19 guidelines, LPA observed staff wearing face masks, and were following CDC and Dept of Public Health Guidelines

Incident #1 occurred on 02/01/22 involving Staff#1(S1) and Child #1(C1).
Incident #2 occurred on 11/04/21 involving S1 and C2.

LPA reviewed 1 staff file and two children files, interviewed one staff and attempted to interview C1. LPA was unable to qualify C1.

Due to insufficient information available at this time further investigation is required.

An exit interview as conducted. Notice of Site Visit was posted during the visit. The facility representative was informed that the Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100 per day. The licensee was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. First level appeal is to Regional manager, address is above on the report. The facility representative was informed of how/where to access regulations and forms from CCLD website: www.ccld.ca.gov. and accessibility and access to the website was discussed with the care provider. This report is to be on file and accessible for public review at the facility for at least 3 years.
SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Pat Rivas
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2022
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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