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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371540
Report Date: 01/19/2022
Date Signed: 01/19/2022 05:19:59 PM

Document Has Been Signed on 01/19/2022 05:19 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:SEASIDE COSTA MESA PRESCHOOLFACILITY NUMBER:
304371540
ADMINISTRATOR:BENITEZ, PERLAFACILITY TYPE:
850
ADDRESS:1701 BAKER STREETTELEPHONE:
(909) 616-1101
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 70TOTAL ENROLLED CHILDREN: 70CENSUS: 0DATE:
01/19/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator Ms. Benitez, Perla TIME COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA) Ms. Desai, Ketki conducted an announced on site pre-licensing inspection at the childcare center. It is a new center on the Church premises.

LPA met with Facility Administrator Ms. Benitez, Perla who gave a tour of the new Child Care Center.
The applicant has requested to provide care and supervision for 70 Pre-school age children 2 to 6 years (Entry into First grade), Monday through Friday 7:00 AM-6:00PM. Full day session from 8:00 AM to 5:00 PM and Part time sessions from 9:00 am -12 PM (Children do not nap during the half day session) or three full days along with Day care options: Before and after care from 7:00 AM to 9:00 AM and 3:00 PM and 6:00 PM, in the assigned six classrooms. Due to COVID 19, LPA observed representatives wearing face mask, social distancing and following CDC and Dept of Public Health Guidelines.

Due to COVID Pandemic parents shall be encouraged to follow the CDC and COVID requirements, children shall be received at the entrance door by the staff, temperatures shall be checked, hands sanitized before they are taken to their classrooms.

A review of the 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.

The facility is located on the Church grounds (Education center building) there is parking lot in front of the building, parents shall access the building from the South entrance. Sign in procedure is a digital Bright Wheel application where parents can use their phones, as well as I-Pads, which are placed in each room for electronic sign in's.

All the six classrooms are located on same level with play yards surrounding the building. (Page -1)
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2022
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 7
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: SEASIDE COSTA MESA PRESCHOOL
FACILITY NUMBER: 304371540
VISIT DATE: 01/19/2022
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This facility plans to provide Incidental Medical Services – IMS. For IMS information, see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. A Plan of Operation that includes IMS must be submitted to the Department. 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

Medication will be stored in the classrooms in a locked cabinet and shall be administered by the teacher or the Facility in charge, Emergency first aid kits are stored in the classrooms and in the in assigned cabinets. Medication administration forms were reviewed and stored in the Director's office.
Isolation area is the designated room in the Church Administrative building adjoining the Day care building, which can be accessed through the play yard, or the front entrance of the facility. This room is equipped with a couch and 2 bathrooms, the bathroom has a sign designated for Day care children only, additional linens are available for the sick child. During the time child is waiting to be picked up, Facility staff shall remain with the child.

LPA discussed the posting requirements, this posting are posted at the entrance on the left hand side on the parent board.
· Facility License in public area (101160)
· Emergency Disaster Plan (LIC 610)
· Earthquake Preparedness Check List (LIC 9148)
· Parents’ Rights Poster (PUB 393)
· Personal Rights (LIC 613A)
· Menus / Activity Schedule
· Notice of Site Visit (LIC 9213) and Type A deficiencies / Plan of Corrections of Type A deficiencies
· Granted Waivers (available for review)
· Child Car Seat Law (PUB 269)
· COVID Posters.

The Administrator's office is adjoining the classroom at the end of the lobby (Page-2)
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2022
LIC809 (FAS) - (06/04)
Page: 2 of 7
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: SEASIDE COSTA MESA PRESCHOOL
FACILITY NUMBER: 304371540
VISIT DATE: 01/19/2022
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The following were inspected in the indoor activity space:
· Classroom are adequately equipped with age and size appropriate furniture and equipment
· Drinking water is available inside through Brita filtered pitchers or personalized water bottles and it shall be refilled as needed.
· Sign in/Sign out procedure was reviewed and meets regulation requirements (Electronic sign in and out)
· There is a working smoke detector, carbon monoxide detector and fire extinguisher that meet statutory requirements.
· Cubbies available for storage of individual child’s personal belongings and/or bedding
· Napping equipment: Cots are used for Preschool age children, napping linens and blankets are provided by the parents and are taken home on a weekly basis.
· Facility provides two snacks and lunch is brought from home. Containers shall be stored and labeled accordingly.
Each room was observed to have one sink along with toilet in between the rooms.
Room # 3 (Pink room) is designated room for younger preschool age children with Diapers, it has a changing station and a sink within arm's reach..
Toileting training shall be provided in Room # 5 (Green room) additional Potty chairs are available in this room along with a baby toilet.

On today's inspection all the six rooms were measured with the following measurements:

Room Identification Length Width Area Encumbered Space
Room #1 (Purple)
23.17
17.92
415.21
415.21
Room # 3 (Pink)
23.75
17.92
425.60
425.60
Room # 5 (Green)
31
17.92
555.52
37.92
517.60
Room # 2 (Orange )
15.25
17.25
263.06
263.06
Room # 4 (Turquoise)
15.08
17.25
260.13
260.13
Room # 6 (Blue)
35
17.25
603.75
30.23
573.52

Total indoor space: 2455’12 divided by 35 = 70’15 ( 70 children) As requested. (Page-3)

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2022
LIC809 (FAS) - (06/04)
Page: 3 of 7
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: SEASIDE COSTA MESA PRESCHOOL
FACILITY NUMBER: 304371540
VISIT DATE: 01/19/2022
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Each classroom has one sink and toilet for the children. Both sinks and toilets were age appropriate for younger preschool children.
Total sinks : 6 X 15= 90 children and Total Toilets/ Urinals: 6 X 15= 90 children

The following were inspected in the outdoor activity space;

Facility has two play yards adjoining the facility, one play yard on the right side will be accessed from each of the following three classrooms Room # 1, 3 and 5 , while the second play yard is the nature yard designed for gardening/ water play and sand play for the children. This yard shall be accessed by walking through the lobby area to the side gate opening into the yard. Both the yards were observed to be safe for outdoor activities.
· Play yards are fully enclosed by an appropriate fencing
· Drinking water is available outdoors by personalized water bottles / Brita Filer with paper cups
· Outdoor activity space is supplied with age and size appropriate equipment, including climbing play structures and outdoor activity toys,
· An adequate amount of cushioning material consisting soft cushion is in place under the play structure
· Adequate shade is provided by shaded canopy sail along with the roof line of the building.

Outdoor measurements:
Area Identification LengthWidth
Area
Encumbered
Space
Preschool yard # 1
88.42
38.42
3397.10
3397.10
Nature yard
55.58
50.5
2806.79
2806.79

Total outdoor activity space: 6,203'89 divided by 75= 82'71 (83 children)

Based on the indoor and outdoor measurements, sink and toilet availability, facility has sufficient space to accommodate 70 Preschool children ( 2-6 years old- entry into first grade as requested in the assigned six classrooms.
Facility Administrator is current on the required Immunization/ Pediatric CPR/ First training valid through
Dec 31st 2023 and have provided the completion certificate for the Preventive Health training (Nutrition and Lead component. (Page-4)
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2022
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: SEASIDE COSTA MESA PRESCHOOL
FACILITY NUMBER: 304371540
VISIT DATE: 01/19/2022
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The applicant was given a pamphlet on Lead Exposure and was discussed with provider. Also provided was information about the E-Learning Modules available at https://ccld.childcarevideos.org. The Chaptered Legislation for AB 2084 (Nutritious Beverages) is available to view on the website at: http://ccld.ca.gov/res/pdf/12APX-11.pdf

Applicant was informed of Mandated Reporter Training for self and all assistants. Department web site form was given to down load forms, Title 22 regulations, and training's on-line at www.ccld.ca.gov. The applicant was also informed to visit the website for Quarterly Updates. The applicant was advised on how to receive notifications for quarterly updates and provided with Child Care Advocate contact information: childcareadvocatesprogram@dss.ca.gov. or at www.ccld.ca.gov

LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian. Facility has access to the new system.
Information on the additional nutrition training, immunization requirements for children, and Health Schools Act (http://www.cdpr.ca.gov/docs/pestmgt/schoolipm.htm) were provided. The applicant/facility representative was informed, and website given, about the California Child Care Disaster Plan has been posted to the UCSF California Childcare Health Program website: cchp.ucsf.edu/content/disaster-preparedness

Facility has provided the Water testing report for Lead component.

The facility was following Title 22 requirements at the time of the inspection. Based on today’s measurements, and the sink and toilet availability, this center has sufficient activity space to support the capacity of 70 Preschool children in Room # 1 (Purple) Room # 2 (Orange), Room 3 (Pink), Room 4 (Turquoise), Room # 5 (Green) and Room # 6 (Blue). A license will be issued for the capacity of 70 preschool children age 2-6 years old (entry into first grade), in the above rooms Monday to Friday 6:00 AM to 7:00PM after a final review.

Fire clearance received from Costa Mesa Fire Authority have approved the requested capacity of 70 Preschool children in the assigned six rooms. (Page 5)
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2022
LIC809 (FAS) - (06/04)
Page: 5 of 7
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: SEASIDE COSTA MESA PRESCHOOL
FACILITY NUMBER: 304371540
VISIT DATE: 01/19/2022
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Facility Representative Ms. Benitez, Perla 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, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA reviewed with facility representative Ms. Benitez Perla the LIC 311A, Records To Be Maintained At The Facility, for child’s records, personnel records, administrative records, and documents to be posted.

LPA also discussed the following with Ms, Benitez Perla :

Subscribe to CCLD important information

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 platform.

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 communication.

A child teacher ratio capacity handout was also shared with the facility representative.


Applicant was also advised, once licensed, the Notice of Site Visit must be posted for 30 days and if A violations are cited then the Licensing Report (LIC809 or 9099) must be posted by the Notice of Site Visit for a period of 30 days or $100 civil penalties will be assessed, and the report shall posted and copies provided to the parents/guardians of the children in care at the facility by the next business day, and shall provide to the parents/guardians of children newly enrolled at the facility during the next 12 months. In addition, the licensee shall immediately post upon receipt the Proof of Correction for 30 consecutive days and provide a copy to current and enrolling parents. The licensee is to keep Acknowledgement Receipt (LIC 9224) signed by parents in each child’s file.

(Page-6)
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2022
LIC809 (FAS) - (06/04)
Page: 6 of 7
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: SEASIDE COSTA MESA PRESCHOOL
FACILITY NUMBER: 304371540
VISIT DATE: 01/19/2022
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Appeal Rights were discussed. The applicant was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Licensing office within 15 business days.

Exit interview conducted and report was reviewed with the Facility Representative Ms. Benitez, Perla

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2022
LIC809 (FAS) - (06/04)
Page: 7 of 7