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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304370408
Report Date: 09/07/2022
Date Signed: 09/07/2022 11:42:29 AM

Document Has Been Signed on 09/07/2022 11:42 AM - 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:PACIFIC DRIVE ELEMENTRY SCHOOLFACILITY NUMBER:
304370408
ADMINISTRATOR:COSGROVE, MARILEEFACILITY TYPE:
850
ADDRESS:1501 W. VALENCIA DRIVE, #33TELEPHONE:
(714) 447-7735
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 19DATE:
09/07/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Linda Prieto and Vanessa RosasTIME COMPLETED:
11:00 AM
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An unannounced case management inspection was conducted on this date by Licensing Program Analyst (LPA) Valencia. The facility is moving back to rooms #32 and 33, from a portable room #35. The facility is currently licensed for 24 and will remain at this capacity. The facility is located at Pacific Drive Elementary School campus. LPA met with Linda Prieto, Supervisor, who guided analyst on a tour of the facility. Operations hours are Monday-Friday; the facility has two sessions: AM session: 8:00AM-11:00AM and PM session: 12:00PM-3:00PM; serving children ages 3-5 years old. The facility is closed during winter and summer breaks. A review of staff records on this date indicates that all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.

All areas identified on the Facility Sketch were inspected. If children become ill during the day, they will rest in the isolation area located, in the front office, in the nurse’s office. There is also a bathroom in the office that will be used for the ill children. Medication will be stored in the classroom, in a locked cabinet. Furniture and equipment were inspected for age appropriateness and good repair. Age appropriate sinks and toilets were inspected for availability, good repair, water temperature, toilet paper, paper towels, area safety and sanitation. There are 2 toilets and 4 sinks available to the children, as well as a separate staff restroom. Children bring their own water bottles from home and the school provide water, if needed. First Aid supplies were inventoried. Sign in / sign out procedure was inspected and in compliance. School provides breakfast for AM session and lunch for PM session. Facility pick up the food at the school cafeteria, located on campus.
Indoor Activity Space Measurements:
1289 sq ft. = 36 children

Total children toilets and sinks:
Toilets: 2 x 15 = 30 children
sinks: 4 x 15 = 60 children (continued on LIC809C)
SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Dean Valencia
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: PACIFIC DRIVE ELEMENTRY SCHOOL
FACILITY NUMBER: 304370408
VISIT DATE: 09/07/2022
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(page 2)

Outdoor Activity Space Measured today 9/7/22:
approximately 25x42 + 63x87 = divided by 75= 87 children

Playground is completely enclosed. An adequate amount of cushioning material is in place under the equipment. Shade is provided by an awning and tree. Drinking water is available by children bringing their water bottles from home and a water jug is available for refills.

Fire clearance approval letter from OCFA received by LPA on 8/29/22.
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

In the areas evaluated, no deficiency was observed and cited today per CA Code of Regulations, Title 22, and Division 12. A license will be issued for the capacity of 24, pending managerial approval. Exit interview was conducted. A copy of this report and appeal rights were discussed and provided to the director. The Notice of Site Visit was posted. The director 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
SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Dean Valencia
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022
LIC809 (FAS) - (06/04)
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