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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300610675
Report Date: 11/28/2023
Date Signed: 11/28/2023 01:26:23 PM

Document Has Been Signed on 11/28/2023 01:26 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 CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:CAPISTRANO USD/SAN JUAN STATE PRESCHOOLFACILITY NUMBER:
300610675
ADMINISTRATOR:BRIERLEY, NENAFACILITY TYPE:
850
ADDRESS:31642 EL CAMINO REAL, #3TELEPHONE:
(949) 493-4533
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY: 48TOTAL ENROLLED CHILDREN: 48CENSUS: 21DATE:
11/28/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Facility representativeTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA), Mahnaz (Nancy) Malek conducted an onsite case management inspection for the purpose of checking into an incident that the facility reported to our office on 11/20/2023. LPA met with facility representative, Heidi Argent. LPA took census. There were a total of 8 preschool children with 2 staff in room # 43 and there were 13 preschool children present with 2 staff in room 42. According to the self incident report, 3 year old child was pushed in the back by staff # 1.

A review of the Facility Personnel Report Summary on this date indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. (The staff are employees of Capistrano Unified School District).

Today LPA interviewed staff # 1, staff # 2, and staff # 3 who were involved in the incident. Staff # 1 denied pushing child # 1. Staff # 1 stated staff did not get physical with the child at all. Staff # 1 stated staff was on the playground with 9 children while staff # 2 was in the classroom with child # 1. Child # 1 got out of the classroom running around the black top on the elementary school site. Staff # 2 was following child # 1 around. Staff # 2 instructed staff # 1 to close the gate so staff # 2 can reach to child # 1 at the gate before the child enters another open area. Staff # 1 stated staff went and closed the gate. Staff # 1 observed child # 1 fell on the bottom gently and got up while staff was playing with the latch of the gate. Staff denied having any physical contact with child # 1. Staff # 1 stated the gate was high and staff could not reach the child on the other side for any physical contact. LPA interviewed staff # 2 whom staff stated was following the child around outside the playground on the black top. Staff # 2 told staff # 1 who was in the playground to close
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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE: DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/28/2023
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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: CAPISTRANO USD/SAN JUAN STATE PRESCHOOL
FACILITY NUMBER: 300610675
VISIT DATE: 11/28/2023
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the gate so staff # 2 could get to the child at the gate. Staff # 2 stated staff did not see staff # 1 to get physical with child # 1. Staff # 2 observed child # 1 stumbled back at the gate but did not fall. LPA interviewed staff # 3 whom staff said was getting close to the gate on the black top of the elementary school. Staff # 3 who was 20 feet away from the gate witnessed staff # 1 pushed the child back with hands open and child # 1 stumbled back but did not fall. LPA attempted to interview child # 1 but was not successful. There are no other witnesses to this incident.

Based on the interviews with 3 staff, and attempted interview with child # 1, LPA found out there were discrepancies in 3 staffs' statements. Therefore there is not enough evidence to prove the incident of staff # 1 has pushed the child back or not.

In the areas that were evaluated, no deficiency was cited of the California Code of Regulations, Title 22, Division 12 Section.

A notice of site visit was given to facility representative, Heidi Argent. and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

Exit interview conducted and report was reviewed with the facility representative, Heidi Argent.

End of report

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:

DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023
LIC809 (FAS) - (06/04)
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