Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304270251
Report Date: 10/24/2017
Date Signed: 10/24/2017 12:52:13 PM

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:MISSION BASILICA SCHOOLFACILITY NUMBER:
304270251
ADMINISTRATOR:BULLOCK, LAURAFACILITY TYPE:
850
ADDRESS:31641 EL CAMINO REALTELEPHONE:
(949) 234-1385
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY:45CENSUS: 32DATE:
10/24/2017
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Laura BullockTIME COMPLETED:
01:00 PM
NARRATIVE
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An inspection was conducted at the facility by LPA Connolly and LPA Valencia. The facility file was reviewed prior to this visit. A review of staff records indicates all facility staff or individuals who require caregiver background checks have received a criminal record clearance or exemption and a child abuse index clearance.

Operating hours are 7:00 AM -- 5:30 PM. The facility was toured inside and outside and the floor and yard plan were verified. During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staffing ratios. The facility appeared clean and orderly. The items which could pose a danger to children (detergents, cleaning compounds, and medications) were stored out of the reach of children. Lunches and snacks are brought from home. The toys, floors, desks and other equipment appeared clean. There is drinking water available to children both indoors and outdoors. The children's bathrooms are clean and sanitary. Children nap on cots, and bedding, individually stored, is laundered weekly at home. The facility has conducted an emergency drill within the past six months. The facility has a working smoke detector, carbon monoxide detector, and fire extinguisher. The playground was completely fenced. The playground equipment appeared in safe condition, and play area is free from hazards. There is sufficient cushioning underneath climbing structures and play equipment to absorb falls. Sign in/out procedure was reviewed for compliance. During today's visit staffing ratios were being met. At least one staff member present possesses current CPR/First Aid certifications, which expire July 2019. Children's and staff files were reviewed for compliance. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated 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
(continued on Page 2).
SUPERVISOR'S NAME: Marian WallmeierTELEPHONE: (703) 703-2800
LICENSING EVALUATOR NAME: Gesine ConnollyTELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2017
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: MISSION BASILICA SCHOOL
FACILITY NUMBER: 304270251
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/21/2017
Section Cited
HSC
1596.7995
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Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
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The director stated she will submit all four staff's record of immunizations, by 11/21/2017.
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Four staff present during the inspection (see Staff Records review LIC859), did not have proof of immunization against pertussis, influenza (or written declination), and measles available for review. This is a potential threat to the children's health and safety.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Marian WallmeierTELEPHONE: (703) 703-2800
LICENSING EVALUATOR NAME: Gesine ConnollyTELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2017
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2017
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: MISSION BASILICA SCHOOL
FACILITY NUMBER: 304270251
VISIT DATE: 10/24/2017
NARRATIVE
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Proof of immunization's against pertussis, influenza (or written declination), and measles for all employees/volunteers were reviewed for compliance with SB 792. All licensing reports are public information and must be made available upon request. This report was reviewed and discussed with the licensee. Facility was advised on how to receive notifications for quarterly updates and provided with Child Care Advocate contact information: childcareadvocatesprogram@dss.ca.gov

Exit interview was conducted. The report was reviewed and discussed. 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. The facility was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. The facility representative was informed of how/where to access regulations and forms from CCLD website: www.ccld.ca.gov This report is to be on file and accessible for public review at the facility for at least 3 years.

The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D.
SUPERVISOR'S NAME: Marian WallmeierTELEPHONE: (703) 703-2800
LICENSING EVALUATOR NAME: Gesine ConnollyTELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2017
LIC809 (FAS) - (06/04)
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