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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304270114
Report Date: 09/23/2024
Date Signed: 09/23/2024 03:33:53 PM

Document Has Been Signed on 09/23/2024 03:33 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:CAPISTRANO UNIFIED SCHOOL DISTRICT-CLARENCE LOBOFACILITY NUMBER:
304270114
ADMINISTRATOR/
DIRECTOR:		JESSICA PONSENFACILITY TYPE:
850
ADDRESS:200 AVE. VISTA MONTANATELEPHONE:
(949) 234-5341
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92672
CAPACITY: 24TOTAL ENROLLED CHILDREN: 13CENSUS: 5DATE:
09/23/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Jessica PonsenTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA), Cindy Nguyen conducted an onsite inspection for the purpose of an Annual/Random. LPA and the facility representative toured the facility inside and outside, and the floor and yard plan (LIC 999) were verified. Census was taken, LPA observed five preschool age children and one staff member. During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staff to child ratios. Facility operates a morning and an afternoon session. The morning session operates from 8:00 AM to 11:00 AM and the afternoon session operates from 11:45 PM to 2:45 PM. The staff are exempt from fingerprint clearances as they are fingerprinted through Capistrano Unified School District. Waiver for shared restrooms and playground are on file.

During the inspection of the indoor activity space, items which could pose a danger to children (detergents, cleaning compounds, and medications) were observed to be stored out of the reach of children. Poisons/Hazardous Items are not kept on the premises. Food is delivered to the facility, snack is provided for the morning session and lunch is provided to the afternoon session. Menus are posted where they can be reviewed by parents. LPA observed a small trash can with some food inside without a cover/lid. Floors, equipment, and furniture were clean and observed to be in good repair and free of sharp edges. There is drinking water available to children indoors by water bottles with the child’s name on it. The children's bathrooms are clean and sanitary. The facility has conducted an emergency drill within the past six months and keeps documentation of drills. The facility has a at least one working smoke detector, one working carbon monoxide detector and at least one functioning fire extinguisher. Facility meets all posting requirements.

The outdoor activity space was inspected for compliance. The playground is enclosed by a fence at least four feet in height and is in good repair. The surface of the outdoor activity space is maintained and free of hazards.

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SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Cindy Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2024
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 6
Document Has Been Signed on 09/23/2024 03:33 PM - It Cannot Be Edited


Created By: Cindy Nguyen On 09/23/2024 at 02:24 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: CAPISTRANO UNIFIED SCHOOL DISTRICT-CLARENCE LOBO
FACILITY NUMBER: 304270114

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101239(f)(1)
Fixtures, Furniture, Equipment and Supplies
(f) Solid waste shall be stored, located and disposed of in a manner that will not transmit communicable diseases or odors, create a nuisance, or provide a breeding place or food source for insects or rodents. (1) All containers used for storage of solid wastes, including moveable bins, shall have a tightfitting cover that is kept on; shall be in good repair; and shall be leakproof and rodent-proof.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. LPA observed a small trash can with some food inside without a cover which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2024
Plan of Correction
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Staff stated will replace trash can with a lid. Verification of correction needs to be sent to LPA via email at Cindy.Nguyen@dss.ca.gov by the due date.
Type B
Section Cited
CCR
101216(f)
Personnel Requirements
(f) At least one staff member who is trained in pediatric cardiopulmonary resuscitation and pediatric first aid pursuant to Health and Safety Code Section 1596.866 shall be present when children are at the child care center or offsite for center activities.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's interview and record review the facility did not comply with the section cited above and failed to keep Pediatric CPR and First Aid current, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2024
Plan of Correction
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Staff will provide proof of Pediatric CPR/First Aid from Heart Savers, Red Cross or EMS approved to LPA via email at Cindy.Nguyen@dss.ca.gov by the due date.
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:Patricia Magana
LICENSING EVALUATOR NAME:Cindy Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2024


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 09/23/2024 03:33 PM - It Cannot Be Edited


Created By: Cindy Nguyen On 09/23/2024 at 02:24 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: CAPISTRANO UNIFIED SCHOOL DISTRICT-CLARENCE LOBO
FACILITY NUMBER: 304270114

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101229.1(b)
Sign In and Sign Out
(b) The person who brings the child to, and removes the child from, the center shall sign the child in/out.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above, child #1 missing sign out signatures for 09/09 -09/12, 09/16-09/20, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2024
Plan of Correction
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Staff will provide proof via email the communication occuring with parent to ensure this task is being completed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Patricia Magana
LICENSING EVALUATOR NAME:Cindy Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2024


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: CAPISTRANO UNIFIED SCHOOL DISTRICT-CLARENCE LOBO
FACILITY NUMBER: 304270114
VISIT DATE: 09/23/2024
NARRATIVE
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The cushioning material of rubber mats outdoor play equipment and other similar equipment appeared to be enough to absorbs falls. Drinking water in the outdoor activity space is provided by water bottles with the child’s name on it. The outdoor equipment and toys are in good repair and free of sharp edges. There are no bodies of water present at the facility. The inspected outdoor facility grounds are safe, sanitary and in good repair.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test. For childcare center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1- CCP).

LPA verified that the lead testing was completed on 11/30/2022. The report results dated 12/15/2022 determined there was no lead exceedance in accordance to the Written Directives outlined in PIN 21-21.1-CCP.



Staff files were reviewed for staff present during the facility inspection on this date, one staff file was reviewed. Health screening and immunizations as required were reviewed. Beginning September 1, 2016, Health and Safety (H&S) 1596.7995 states, a person shall not be employed or volunteer at a childcare center if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles for staff were reviewed and within compliance. Beginning March 31, 2018, H&S Code 1596.8662 requires all directors and employees to complete mandated reporting training, and to renew the training every two years. Staff member present EMSA approved Pediatric CPR/First Aid certifications, which expires 02/2024.

Children's records were reviewed, and there was a separate, complete and current record for each child. Five children's files were reviewed for documentation of the child’s name, address, and telephone number of the child’s authorized representative and of relatives or others that can assume responsibility for the child if the authorized representative cannot be reached when necessary, Immunization records, Consent for Emergency Medical Treatment, Notification of Parent’s Rights (LIC995A), medical assessment and found to be in compliance. In the areas reviewed the children’s files were found to be in full compliance.
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SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Cindy Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024
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: CAPISTRANO UNIFIED SCHOOL DISTRICT-CLARENCE LOBO
FACILITY NUMBER: 304270114
VISIT DATE: 09/23/2024
NARRATIVE
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Sign in/out procedure was reviewed for compliance. The person who signs the child in and out uses their full legal signature and records the time of the day. Child #1 missing sign out signatures for 09/09 -09/12, 09/16-09/20.

The facility representative was informed that Licensing Quarterly Updates are available at www.ccld.ca.gov licensee may request to be added to an email list to receive a Quarterly Update by contacting the Child Care Advocate at 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

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 licensee 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 Also provided was information about the E-Learning Modules available at https://ccld.childcarevideos.org A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the facility representative.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Important COVID-19 resources and links were provided:
· COVID-19 Update Guidance Childcare Programs/Providers link:
https://files.covid19.ca.gov/pdf/guidance-childcare.pdf (Page 3 of 4)
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Cindy Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024
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: CAPISTRANO UNIFIED SCHOOL DISTRICT-CLARENCE LOBO
FACILITY NUMBER: 304270114
VISIT DATE: 09/23/2024
NARRATIVE
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· CCLD COVID-19 Licensed childcare and facilities and provider FAQs link: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/child-care-licensing/covid-19-child-care-resources/faqs-for-licensed-child-care-facilities-and-providers

Facility representative was reminded that all adults 18 and over, 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.

This facility provides Incidental Medical Services – IMS. LPA reviewed the storage of medication, equipment, and supplies and reviewed children’s, personnel, and administrative records. A link to PIN 22-02-CCP was provided here: PIN 22-02-CCP: Best Practices Related to the Provision of Incidental Medical Services in Child Care Centers and Family Child.

Based on LPA observation, record reviews and interview the following violation was observed and are being cited in accordance with California Code of Regulations, Title 22, Division 12, Chapter 3, Section 101239(f)(1), 101216(f) and 101229.1(b) are being cited on the attached LIC 809D.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Exit interview conducted and report was reviewed with the facility representative, Jessica Ponsen. A notice of site visit was given and must remain posted for 30 days. Appeal Rights and deficiencies were discussed. The facility representative was provided a copy of their 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.
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Cindy Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024
LIC809 (FAS) - (06/04)
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