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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304370512
Report Date: 07/28/2025
Date Signed: 07/28/2025 12:10:45 PM

Document Has Been Signed on 07/28/2025 12:10 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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:CENTRALIA STATE PRESCHOOL AT SAN MARINOFACILITY NUMBER:
304370512
ADMINISTRATOR/
DIRECTOR:		ESTRADA, SUSANFACILITY TYPE:
850
ADDRESS:6215 SAN ROLANDO WAY #3 & 4TELEPHONE:
(714) 228-3153
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 50TOTAL ENROLLED CHILDREN: 50CENSUS: 0DATE:
07/28/2025
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Estrada, Susan (School Readiness/Child Development Coordinator)TIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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On July 28, 2025 Licensing Program Analysts (LPA) Vivian Trinh, and (LPA), Mahnaz (Nancy) Malek conducted an unannounced case management inspection for the purpose of increasing the preschool capacity from 50 to 100 preschool children. Currently, Facility is license for 50 preschool children in rooms 3, and 4. LPAs met with School Readiness/Child Development Coordinator, Estrada, Susan. There were no children present today, due to summer break. Licensee is requesting to be licensed for 100 preschool children aged 3 to 5 years old in Room 3, 4. 26, and C10. Hours of operation will be Monday through Friday, Morning Shift 8:15am- 11:15am, Afternoon Shift 12:00 noon to 3:00pm.

This site is located on the Centralia School District, State Preschool at San Marino Elementary School.

All indoor and outdoor activity spaces for children were inspected and measured today. There are operational carbon monoxide detectors located in each of the classrooms. All required licensing documents were observed posted in the front entrance. Children will be signed in and out at front in each of the classrooms manually.

INDOOR INSPECTION: Total indoor activity space measured was 3583.56 square feet, which is sufficient to accommodate the requested overall capacity of 100 Children. LPAs viewed age-appropriate furniture and equipment, including tables, chairs, cubbies, bookshelves, and other activity supplies for the children. Drinking water is available in the classrooms via the children's own water bottle with their names on it. LPAs observed all hazardous items to be inaccessible to children. There are no bodies of water or weapons on the property. Fire clearance was granted for 100 children ages 3 to 5 years old in rooms 3, 4, 26, and C10.

LPAs observed a total of 10 sinks and 11 toilets, and 6 urinals available for children’s use. (C10, has 3 toilets, and 3 sinks for children use). There are 2 toilets, 2 sinks, and 6 urinals in boy’s restroom, and 6 toilets, 2 sinks in girl’s restroom, which a waiver will be requested for this purpose. There is one (1) sink in room #3, #4, and room #26. Continued page 2.

NAME OF LICENSING PROGRAM MANAGER: Nguyen K Tran
NAME OF LICENSING PROGRAM ANALYST: Vivian Trinh
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: CENTRALIA STATE PRESCHOOL AT SAN MARINO
FACILITY NUMBER: 304370512
VISIT DATE: 07/28/2025
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The staff bathroom is available in the office area. The isolation area for children is the Nurse’s office equipped with a cot. A toilet and sink in the lobby is designated for sick children's use.

ON-SITE FOOD PREPARATION: Food is prepared off-site at a central kitchen and is distributed to the facility; breakfast and lunch are provided

OUTDOOR INSPECTION: The facility playground is all fenced at least 4 feet high, and located on Elementary site will be shared with transitional kindergarten and kindergarten children. A wavier will be requested. Shade is provided. There are sufficient outdoor age-appropriate toys and play equipment available on the playground. There are enough cushioning on the playground. LPAs observed slides, and 4 swings on the playground. (Built in commercial foam).

LEAD TESTING: Drinking water is available via children's own water bottles which can be refilled in the refillable station. For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1- CCP). The facility updated the lead testing for water to reflect the new room on 7/25/2025. There was no lead exceedance on the report observed by LPAs.

CRIMINAL RECORD CLEARANCE: The School Readiness/Child Development Coordinator, Estrada, Susan was reminded that all adults 18 and over responsible for administration or direct supervision of staff, persons who provides care and supervision to children, and staff who have contact with children, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, medications will be kept in nurse’s office in a locked container(if needed also a refrigerator) Life saving medications will be kept locked in the classrooms. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (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

Continued Page 3.

NAME OF LICENSING PROGRAM MANAGER: Nguyen K Tran
NAME OF LICENSING PROGRAM ANALYST: Vivian Trinh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: CENTRALIA STATE PRESCHOOL AT SAN MARINO
FACILITY NUMBER: 304370512
VISIT DATE: 07/28/2025
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The School Readiness/Child Development Coordinator, Estrada, Susan was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California. LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at:https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communications.

The School Readiness/Child Development Coordinator, Estrada, Susan was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

In the areas that were evaluated, no deficiencies were observed of the California Code of Regulations, Title 22, Division 12 at this inspection date.

Fire clearance has been granted for the requested capacity on 6/26/2025. Based on today's measurement of indoor/outdoor, and the number of sinks and toilets, the facility meets the requirements for the requested capacity of 100 preschool children. The facility will be granted an increasing capacity of 100 preschool children, based on the limited outdoor space measurements. An updated license for 100 preschool children will be approved after final review and approval of the waiver for playground and restroom. A waiver approval is needed for using the playground, and restroom to share with T/K, and Kindergarten on different scheduling. Please submit the following for waiver approval no later than 30 days of today's report.

Continued Page 4.

NAME OF LICENSING PROGRAM MANAGER: Nguyen K Tran
NAME OF LICENSING PROGRAM ANALYST: Vivian Trinh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: CENTRALIA STATE PRESCHOOL AT SAN MARINO
FACILITY NUMBER: 304370512
VISIT DATE: 07/28/2025
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1- Waiver request letter for sharing playground and restroom.
2- Sketch of the outdoor space
3- Photo of the playground
4- LIC 500

A notice of site visit was given to School Readiness/Child Development Coordinator, Estrada, Susan and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Exit interview was conducted with School Readiness/Child Development Coordinator, Estrada, Susan

End of report.

NAME OF LICENSING PROGRAM MANAGER: Nguyen K Tran
NAME OF LICENSING PROGRAM ANALYST: Vivian Trinh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2025
LIC809 (FAS) - (06/04)
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