Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406209167
Report Date: 06/01/2015 12:00:00 AM
Date Signed 06/02/2015 07:50:49 AM

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:PACHECO ELEMENTARYFACILITY NUMBER:
406209167
ADMINISTRATOR:SHANNON JOHNSONFACILITY TYPE:
840
ADDRESS:375 FERRINITELEPHONE:
(805) 781-7247
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY:56CENSUS: 33DATE:
06/01/2015
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Elizabeth DennyTIME COMPLETED:
02:41 PM
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THIS IS AN AMENDED REPORT TO REFLECT CORRECT TIME NOTED ON REPORT.
TIME BEGAN: 2:30 PM TIME COMPLETED: 3:30 PM

(2) Licensing Program Analyst (LPA) Maria Mueller conducted an annual random visit and met with Site Director, Elizabeth Denny. The center is located at Pacheco Elementary, Room #1. LPA observed 32 children and 4 teachers. The children are engaged in a circle time activity. The classroom is clean and free of toxins. The required forms are posted on the wall. The menu is posted on the refrigerator door. There is water available for children. LPA observed age appropriate tables, chairs, toys, games. books, cubbies and art supplies.

Sampling of children's record reviewed. Teacher's records reviewed.

Ms. Livingstone is current with CPR and First Aid which expires November 15, 2016. Ms. Hayley Sabatini is current with CPR and First Aid which expires June 9, 2015.

Today, no deficiencies cited under Title 22 Division 12.




AMENDED REPORT WAS MAILED FOR SIGNATURE 6-2-2015.
SUPERVISOR'S NAME: Deborah AjaoTELEPHONE: (805) 562-0411
LICENSING EVALUATOR NAME: Maria MuellerTELEPHONE: (805) 729-8797
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2015
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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