<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371293
Report Date: 06/07/2022
Date Signed: 06/07/2022 03:31:40 PM

Document Has Been Signed on 06/07/2022 03:31 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:BOYS & GIRLS CLUBS-SKYLARKFACILITY NUMBER:
304371293
ADMINISTRATOR:JERICA HINOJOSAFACILITY TYPE:
850
ADDRESS:11250 MAC MURRAY STREETTELEPHONE:
(714) 497-7382
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 17DATE:
06/07/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator Ms. Hinojosa, Jerica TIME COMPLETED:
03:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Desai, Ketki conducted an unannounced Case Management Licensee initiated inspection at the above facility for the purpose of Increasing the Preschool capacity in room # G51 and G 52.
The facility is currently licensed for 24 preschool children. LPA Desai, Ketki met with Program Administrator Ms. Hinojosa, Jerica and Program In charge Ms. Pham, Sarah who guided analyst on a tour of the facility. The facility is located on the Skylark Preschool campus, under Garden Grove Unified School district. During the tour of the two classrooms , LPA observed 17 napping children with 4 teachers in the two assigned classrooms.
Currently the facility is operating from 7.00 am to 6.00 PM, Monday to Friday serving children ages 2-5 years old. Facility has a Waiver on file to share the elementary school bathrooms and the playground.

A review of staff records on this date indicates that all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.

All areas identified on the Facility Sketch were inspected. If children become ill during the day, they will rest in the isolation area located, in the nurse’s office, next to the school office, away from the other children, there is also a bathroom located in this area for the ill children to use. Medication will be stored in the classroom, located in a top cabinet. Incidental Medical services are provided. Furniture and equipment were inspected for age appropriateness and good repair. Age appropriate sinks and toilets were inspected for availability, good repair, water temperature, toilet paper, paper towels, area safety and sanitation. The facility provide water inside/outside by a water jug and disposal cups and children bring their own water bottles from home labeled with their names. First Aid supplies were inventoried.

Center provide breakfast / lunch and PM snacks children, which is delivered to the facility by the school district cafeteria. Continue on next page (1 of 2)
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2022
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 2
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: BOYS & GIRLS CLUBS-SKYLARK
FACILITY NUMBER: 304371293
VISIT DATE: 06/07/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Following was observed in the two classroom (G 51 & G 52)
1) Age appropriate furniture and activities including Educational / Arts & Crafts items.
2) Room is well ventilated with proper lighting and shade.
3) There is a working Smoke detector / Carbon Monoxide detectors and Fire Extinguisher.
4) There is a changing table with a portable sink in room # G 52
5) Children shall nap on the cots, linens and blankets shall be brought from home and additional linens are present on site.
6) Parent drop off - pick up: Designated left side gate# 6 (Building G): Electronic sign in using a specific Pin number.

Indoor activity space: 1,680'29= 48. Facility has sufficient space to accommodate 48 preschool age children as requested.

Total sinks : 6 X 15 = 90 children / Toilets: 3 and 1 urinal X 15 = 60 children ( Additional sinks and toilets are available on school campus)

Outdoor Activity Space-Previous Measurements: Total= 67 X 100 = 6,700 sq ft divided by 75= 89 children

Playground is completely enclosed. Outdoor activity area is supplied with age and size appropriate equipment. Adequate shade is provided by Canopies and trees.

Fire clearance approval letter on file and dated 05/31/2022, approving the requested capacity.

In the areas evaluated, no deficiency was observed and cited today per CA Code of Regulations, Title 22, and Division 12.

New License with a capacity of 48 preschool age children (2-5 years) in Room # G 51 & G 52, Monday To Friday shall be issued upon Management approval.

Exit interview was conducted. A copy of this report and appeal rights were discussed and provided to the director. The Notice of Site Visit was posted. The director 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.
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2