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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494365
Report Date: 12/13/2022
Date Signed: 12/13/2022 11:53:47 AM

Document Has Been Signed on 12/13/2022 11:53 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:PACE - OCEANSIDE LEARNING ACADEMYFACILITY NUMBER:
197494365
ADMINISTRATOR:VARGA, JOHNFACILITY TYPE:
850
ADDRESS:682 BROADWAY STREETTELEPHONE:
(424) 280-4090
CITY:VENICESTATE: CAZIP CODE:
90291
CAPACITY: 28TOTAL ENROLLED CHILDREN: 28CENSUS: 22DATE:
12/13/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:48 AM
MET WITH:Davita BrownTIME COMPLETED:
11:50 AM
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On 12/13/2022 Licensing Program Analyst (LPA) Doris Whitmore conducted an unannounced Case Management- Incident inspection for the purpose of following up on an Unusual Incident Report (UIR) submitted on 09/20/2022. LPA met with Davita Brown, Site Lead, who toured the LPA through the inside and outside of the facility. LPA observed 22 children in care and 6 staff. According to the UIR, on 09/20/22 child was given by accident a beef patty instead of special diet veggie patty. During the investigation LPA interviewed Staff #1 Teacher, Staff #2 Site Lead& Staff #3 Sub. LPA observed family style lunch and children sitting at the table. LPA reviewed the Allergy Special List that is posted in each classroom and in the kitchen. LPA reviewed the Transport Record, & Menu. All children who have special diets LPA observed name tags with a yellow stickers. LPA reviewed child's file on the outside of the file there was an sticker that stated Special Diets.

Pee Title 22, Division 12, Chapter 3, California Code of Regulations, no deficiencies are cited. An exit interview was conducted. A copy of this report (LIC809) and Notice of Site Visit were provided to the Site Lead Davita Brown
SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Doris Whitmore
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2022
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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