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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 566207652
Report Date: 06/28/2021
Date Signed: 06/28/2021 12:41:07 PM

Document Has Been Signed on 06/28/2021 12:41 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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:GREAT PACIFIC CHILD DEVELOPMENT CENTERFACILITY NUMBER:
566207652
ADMINISTRATOR:JESSICA DERBYFACILITY TYPE:
840
ADDRESS:259 W.SANTA CLARA ST. 260&280TELEPHONE:
(805) 507-8335
CITY:VENTURASTATE: CAZIP CODE:
93001
CAPACITY: 24TOTAL ENROLLED CHILDREN: 0CENSUS: 18DATE:
06/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Jessica DerbyTIME COMPLETED:
12:45 PM
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On 06/28/2021, at 10:15 a.m. Licensing Program Analyst, (LPA) Jill Laxo conducted an unannounced annual inspection and request by Director for additional outdoor space for the school age program. LPA met with Director, Jessica Derby. The center was toured inside and out. There were seven staff members supervising 18 children. Bathrooms were in safe and sanitary condition and free of hazards. Classroom was adequately equipped with age and size appropriate furniture and equipment was in good condition.

The facility does not provide a food program at this time. No medications are being stored at the facility. Disinfectants and cleaning supplies are inaccessible to children. Drinking water was readily available both indoors and out. Playground was enclosed with equipment in safe condition including cushioning material and was free of hazards. The new play area was measured and inspected. Additional playground is approved and will be added to the licensed area, however, there will be no increase in capacity.

There were no bodies of water. Director stated there are no guns nor ammunition on the premises.

Personnel records were viewed and contained documents for education, AB 1207, health screening, CPR/First Aid expires 11/2021, and criminal background clearance. Sign in/out sheets were viewed. Digital files for three children in the school age program were reviewed and found complete with required licensing forms including authorized representative contact information and Parent Rights.
SUPERVISORS NAME: Ana Tolentino
LICENSING EVALUATOR NAME: Jill M Hazelhofer-Laxo
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2021
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
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: GREAT PACIFIC CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 566207652
VISIT DATE: 06/28/2021
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Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. 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 discussed with Director PIN 20-01 Lead Testing requirements.



No deficiencies were cited during today's visit.

THE NOTICE OF SITE VISIT WAS POSTED.
SUPERVISORS NAME: Ana Tolentino
LICENSING EVALUATOR NAME: Jill M Hazelhofer-Laxo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
LIC809 (FAS) - (06/04)
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