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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371293
Report Date: 02/05/2025
Date Signed: 02/05/2025 12:15:02 PM

Document Has Been Signed on 02/05/2025 12:15 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 COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:BOYS & GIRLS CLUBS-SKYLARKFACILITY NUMBER:
304371293
ADMINISTRATOR/
DIRECTOR:
NAVA, MARISSAFACILITY TYPE:
850
ADDRESS:11250 MAC MURRAY STREETTELEPHONE:
(714) 497-7382
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY: 48TOTAL ENROLLED CHILDREN: 25CENSUS: 14DATE:
02/05/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Marissa NavaTIME VISIT/
INSPECTION COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Dean Thompson conducted an unannounced case management incident inspection in response to a self reported Unusual Incident dated 1/28/2025. LPA met with Director Marissa Nava and toured the facility. LPA observed 14 preschool children with three preschool staff.

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. During the visit, it was determined the facility is operating within its licensed capacity and within compliance of staffing ratios.

On 1/28/2025, a self reported Unusual Incident Report (UIR) was filed with the Licensing Office. The facility reported child #1 (C1) sustaining a cut on the left side of their head from the play kitchen refrigerator door on 1/28/2025.

On 2/5/2025, LPA interviewed staff #1 (S1). According to S1, the door was in working condition and when C1 pulled the door, screws detached from the wooden door, causing the door to fall on C1. LPA observed the screws from the door to not be stripped. Door observed to be free from cracks and sharp edges.

Based on interview with S1, LPA did not observe any violation of Title 22 Regulations.

Exit interview conducted and report was reviewed with Director Marissa Nava. 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.

Appeal Rights were explained. The Director was provided a copy of appeal rights (LIC 9058 01/16) 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. First level appeals should be sent to the regional manager to the address listed above.
SUPERVISORS NAME: Nguyen K Tran
LICENSING EVALUATOR NAME: Dean Thompson
LICENSING EVALUATOR SIGNATURE: DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/05/2025
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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