304371614-3-22-2023-06-CC-MMAK-CQ6PQU-20230322113143

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304371614
Report Date: 03/22/2023
Date Signed: 03/22/2023 11:31:52 AM

Document Has Been Signed on 03/22/2023 11:31 AM - 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:	PACIFIC ACADEMY		FACILITY NUMBER:	304371614
ADMINISTRATOR:	TSENG, TERESA		FACILITY TYPE:	850
ADDRESS:	2987 MESA VERDE DRIVE E		TELEPHONE:	(833) 796-5688
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92626
CAPACITY: 60	TOTAL ENROLLED CHILDREN: 60	CENSUS: 0	DATE:	03/22/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Director, Weili Lin		TIME COMPLETED:	12:00 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	Page 1 of 5 Licensing Program Analyst (LPA) Mahnaz (Nancy) Malek conducted an announced on site pre-licensing inspection at this location for the purpose of opening a new preschool program. The preschool is located on the ground of Pacific Academy Private Elementary School. LPA met with the director, Weili Lin. LPA was given a tour by the director of the entire facility. The applicant has requested to provide care and supervision for 60 preschool children ages 3 to 4 years old, Monday through Friday from 8:00 AM to 5:45 PM. LPA observed the facility is following CDC and Dept of Public Health Guidelines. Due to COVID Pandemic parents shall be encouraged to follow the CDC and COVID requirements. Parents sign in and out electronically at the main office at the entrance of the building or the classrooms. The entrance is from the front side of the building entering from parking lot to the open area where the preschool office and the classrooms are located. Upon arrival each child has an health evaluation along with hand washing before they participate in the activities. Isolation area is in the preschool office area, located at the entrance of the facility and additional cot with bedding is provided for the sick child until the child is picked up. The bathroom for sick children is the bathroom outside preschool office close to office area. One staff person stays with the sick child/children at all times. Continued on page 2

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

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: PACIFIC ACADEMY	FACILITY NUMBER: 304371614
	VISIT DATE: 03/22/2023

NARRATIVE

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LPA discussed the posting requirements including, but limited to, the following:
· Facility License in public area (101160)
· Emergency Disaster Plan (LIC 610)
· Earthquake Preparedness Check List (LIC 9148)
· Parents’ Rights Poster (PUB 393)
· Personal Rights (LIC 613A)
· Menus / Activity Schedule
· Notice of Site Visit (LIC 9213) and Type A deficiencies / Plan of Corrections of Type A deficiencies
· Granted Waivers (available for review)
· Child Car Seat Law (PUB 269)
Safe sleep posters / SIDS

The following was observed in the classrooms:

Classrooms are adequately equipped with age and size appropriate furniture and equipment
Drinking water is available by children's own water bottles, and filtered water container and Dixie cups.
Sign in/Sign out procedure was reviewed.
Facility has built in smoke detectors. There is fire extinguisher mounted that meets statutory requirements. Carbon Monoxide Detector is installed in each classroom.
Cubbies available for storage of individual child’s personal belongings.
Napping equipment: Children in this program will nap on cots, beddings will be provided by the parents and are washed weekly by parents.
Facility has a full day program and facility will provide AM/PM snacks and parents provide lunch to children. Rooms are well lighted with proper ventilation.
Medications are stored in the locked area if any.
First Aid kit and Emergency kit is present.
No food preparation at this site. There is a refrigerator and freezer in the kitchen.

Continued on page 3

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

LIC809 (FAS) - (06/04)

Page: 2 of 5

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: PACIFIC ACADEMY	FACILITY NUMBER: 304371614
	VISIT DATE: 03/22/2023

NARRATIVE

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LPA measured the classrooms and the measurements are as below:
Room 4A is 531.53 square feet
Room 4B is 531.30 square feet
Room 4C is 530.84 square feet
Room 4D is 715.54 square feet

Total indoor capacity for the 4 classrooms are: 2309.22 square feet divided by 35= 65.98
(66 children)

Total sinks: 6 X 15= 90 children. There is one sink in each classroom.
Total toilets: 4 X 15=60 children. There are two toilets in classroom 4D, and one toilet in classroom 4A.
Total urinal: 1 X 5 = 5 children. (urinal is located outside in the outside bathroom). The outside bathroom has one toilet, 2 sinks, and one urinal.

Playground measurement:
Outdoor activity space is 5785 square feet divided by 75 = 77.13 (77 children).
The following was observed for outdoor space:
· The Playground is fully enclosed by appropriate fencing at least 4 feet high. There is a gate on this playground opening to the ground of the elementary school which has a 2nd gate barrier. There is another exit door leading to the outside alley which has additional 2nd barrier gate. The director will change the lock so it is not easily opens by children. The handle is not equipped with a lock. The director was advised the lock shall be out of reach of children for extra caution. LPA discussed the supervision and staff stationing on the playground to watch out for the exit gate on the playground.
· Outdoor activity space is supplied with age and size appropriate equipment.
· There are climbing structure on the playground with adequate cushioning materials.
Shade is provided by awning and umbrellas.
Drinking water is provided by children's own water bottles, and filter water container and Dixie cups.
Fire clearance received from Orange County Fire Authority approving the requested capacity of 60 preschool children. The total measurements of the 4 preschool classrooms, accommodate the requested capacity.
Continued on page 4

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

LIC809 (FAS) - (06/04)

Page: 3 of 5

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: PACIFIC ACADEMY	FACILITY NUMBER: 304371614
	VISIT DATE: 03/22/2023

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The director, Weili Lin is current on the required Immunization/ Pediatric CPR/ First training, the Preventive Health training (Nutrition and Lead component) and Mandated Child abuse reporting training certificate.

Criminal Record Statement : The director was reminded that all adults 18 and over responsible for administration or direct supervision of staff, persons who provides care and supervision to children, and staff who have contact with children, 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.

Safe Sleep LPA discussed the safe sleep regulations with applicant and director 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 the director 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department.
The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

LPA reviewed the LIC 311A, Records to Be Maintained at the Facility, for child’s records, personnel records, administrative records, and documents to be posted.

Continued on page 5

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

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: PACIFIC ACADEMY	FACILITY NUMBER: 304371614
	VISIT DATE: 03/22/2023

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Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.

To receive important license related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

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/process.

A license for 60 preschool children ages 3 to 5 years old, Monday to Friday 8:00 am to 5:45 PM in rooms 4A, 4B, 4C, and 4D will be issued after receiving the following corrections, final review, and management approval. The applicant will be notified if any additional documents are needed before issuing a license. On today's inspection, the director submitted/corrected additional document to LPA which was requested. Please send the following within 30 days of today's date.

1- Posting requirements. (A picture of all the Licensing Posting Requirements).

2- Installing additional lock on the exit gate opening to the back alley. The lock shall be inaccessible to children. The director stated this gate is always locked and it is not for coming and going of staff and parents. There is additional 2nd gate barrier outside this exit gate.

3- Obtaining clearance for the applicant/licensee

End of reports.

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

LIC809 (FAS) - (06/04)

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