Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393620823
Report Date: 12/07/2015
Date Signed 12/07/2015 02:55:48 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:CAPC - GOLDEN WESTFACILITY NUMBER:
393620823
ADMINISTRATOR:BERRIOS, JAMIEFACILITY TYPE:
850
ADDRESS:1031 NORTH MAIN STREETTELEPHONE:
(209) 644-5311
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY:24CENSUS: 0DATE:
12/07/2015
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Stephanie McCoyTIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Bettina Engelman conducted a site visit for the purpose of a prelicensing evaluation. Licensing met with Licensee Representatives, Stephanie McCoy, Deputy Director and Amy Chi, Early Education Director. Also present was Jamie Berrios, Site Coordinator.

INDOOR ACTIVITY SPACE:
The program will be operating in Room 36 on the campus of Golden West Elementary School. The classroom is equipped with child size furnishings. There are individual cubbies for storing children's personal belongings. There is a kitchen to support the food service. Meals will be delivered from the central kitchen. LPA observed 2 sinks with water fountains in the classroom.
The facility has a copy of the following documents posted in a conspicuous area: Parents Rights, Personal Rights, Car Seat Law, Emergency Disaster Plan, Earthquake Checklist, and menu.

The classroom measures a total of 915.91 square feet which will accommodate the requested capacity of 24 preschool children. The program will share use of bathrooms which are located at the end of a building to the south of the building that houses Room 36. LPA observed 2 toilets and 2 sinks in the bathrooms. Applicant submitted a waiver for shared bathroom use. There is a separate staff restroom. Individual measurements are recorded on the Capacity Worksheet (LIC 9024). Children who become ill during the day will be isolated and will use the staff restroom if necessary. LPA observed napping equipment. Program hours will be 7 a.m. – 5:30 p.m.
SUPERVISOR'S NAME: Sharon OgbodoTELEPHONE: (916) 263-5744
LICENSING EVALUATOR NAME: Bettina EngelmanTELEPHONE: (916) 208-3734
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2015
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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: CAPC - GOLDEN WEST
FACILITY NUMBER: 393620823
VISIT DATE: 12/07/2015
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OUTDOOR ACTIVITY SPACE:
The outdoor play area is fenced and is equipped with age-appropriate equipment. There is sufficient resilient material underneath climbing structures and shaded areas supplied by shade structure. Individual measurements are recorded on the Capacity Worksheet (LIC 9024). Staff will supply drinking water in pitchers and bring cups during outside play.


Total = 2,130.74 square feet, sufficient outdoor activity space to support the requested preschool capacity of 24 children.

LPA discussed Incidental Medical Services-IMS, and licensee representatives stated that they will submit the agency’s Plan of Operation for Incidental Medical Services.

As of today’s visit, the facility is licensed with a capacity of 24. An exit interview was conducted.

SUPERVISOR'S NAME: Sharon OgbodoTELEPHONE: (916) 263-5744
LICENSING EVALUATOR NAME: Bettina EngelmanTELEPHONE: (916) 208-3734
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2015
LIC809 (FAS) - (06/04)
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