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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304370947
Report Date: 06/04/2024
Date Signed: 06/04/2024 03:44:38 PM

Document Has Been Signed on 06/04/2024 03:44 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:SAUSD/JACKSON ELEMENTARYFACILITY NUMBER:
304370947
ADMINISTRATOR/
DIRECTOR:
THACH NGUYENFACILITY TYPE:
850
ADDRESS:1143 NAKOMA DRIVETELEPHONE:
(714) 569-3536
CITY:SANTA ANASTATE: CAZIP CODE:
92704
CAPACITY: 48TOTAL ENROLLED CHILDREN: 48CENSUS: 14DATE:
06/04/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Veronica Berber, Early Learning Specialist TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Patricia Duron conducted an unannounced case management investigation regarding a self-reported unusual incident which occurred on 5/21/24. LPA observed 14 preschool children and 3 staff members in the classrooms. Veronica Berber, Early Learning Specialist arrived at approximately 2:00pm.

A review of facility Personnel Report Summary on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. During today's inspection, LPA Duron interviewed 4 staff, and reviewed files (children and staff) LPA obtained facility roster.

Due to insufficient information available at this time, this case management need further investigations.

An exit interview conducted with Veronica Berber, Early Learning Specialist . The Early Learning Specialist was provided a copy of appeal rights (LIC 9058 ) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days.

Notice of Site Visit was provided and must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100.00.

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Patricia Duron
LICENSING EVALUATOR SIGNATURE: DATE: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/04/2024
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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