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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304370846
Report Date: 10/26/2022
Date Signed: 10/26/2022 12:58:36 PM

Document Has Been Signed on 10/26/2022 12:58 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:NOBIS PRESCHOOLFACILITY NUMBER:
304370846
ADMINISTRATOR:NEITZKE, ASHLEYFACILITY TYPE:
850
ADDRESS:26153 VICTORIA BLVD.TELEPHONE:
(949) 661-6258
CITY:CAPISTRANO BEACHSTATE: CAZIP CODE:
92624
CAPACITY: 45TOTAL ENROLLED CHILDREN: 45CENSUS: 32DATE:
10/26/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:02 AM
MET WITH:Director, Ashley NeitzkeTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Patricia Rivas conducted an unannounced case management visit as a result of information obtained during file reviews .


Upon review of 16 staff files LPA noted two staff (S1 and S2) did not have a health screening on file and S1 did not have a tb test on file.
Based on LPAs review of 16 staff files the following violation was observed and is being cited in accordance with California Code of Regulations, Title 22, Division 12 , regulation codes not in compliance 101216(g) Type B deficiency is being cited on the attached LIC 809D.

Exit interview conducted and report was reviewed with the Ashley Neitzke Director. 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.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Pat Rivas
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2022
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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Document Has Been Signed on 10/26/2022 12:58 PM - It Cannot Be Edited


Created By: Pat Rivas On 10/26/2022 at 11:08 AM
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: NOBIS PRESCHOOL
FACILITY NUMBER: 304370846

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/02/2022
Section Cited
CCR
101216(g)1

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Personnel Requirements
All personnel, including the licensee, administrator and volunteers, shall be in good health and shall be physically and mentally capable of performing assigned tasks.Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis
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Director will have S1 and S2 obtain health screenings and will have S1 obtain a tb test with results and submit copies to LPA Rivas by plan of correction date.
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 performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure. This requirement was not met in 2 out of 16 file reviews, S1 did not have health or tb screening done. S2 did not have health screening done. This poses a potential risk to children in care
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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:Rina Lopez
LICENSING EVALUATOR NAME:Pat Rivas
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2022


LIC809 (FAS) - (06/04)
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