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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010214464
Report Date: 03/24/2023
Date Signed: 03/24/2023 04:15:26 PM


Document Has Been Signed on 03/24/2023 04:15 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612



FACILITY NAME:FUSD - CABRILLO STATE PRESCHOOLFACILITY NUMBER:
010214464
ADMINISTRATOR:BRENDA BETHANCOURTFACILITY TYPE:
850
ADDRESS:36700 SAN PEDRO DRIVETELEPHONE:
(510) 792-3015
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:24CENSUS: 14DATE:
03/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Brenda BethancourtTIME COMPLETED:
04:20 PM
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On March 24, 2023 at approximately 12:45pm, License Program Analyst Russ Haderer arrived for an unannounced visit for a required 1 year inspection of this Title V campus. LPA met with the site supervisor, Brenda Bethancourt. Present at today's visit was the site supervisor and Ms. Sara Portillo, and 14 preschool children. The center is in compliance with teacher/child ratios required under Title V.

The facility is a one-room classroom located on the campus of Cabrillo Elementary School. The facility runs separate 3 hour sessions (AM/PM). The facility is clean and well organized with age appropriate furnishings and equipment in good repair. Surfaces including floors and counter tops are free of hazards and toxins. There is a working carbon monoxide (tested) and smoke detectors in the ceilings of the classroom.

Outside play area is shared with the kindergarten school. There are two waivers in place (and properly posted) to 1) ensure a schedule is maintained limiting the number of children in the play area at the same time and 2) allow the children to use the elementary school bathrooms as long as the children are accompanied by facility staff and no elementary children are present.



There is a perimeter fence protecting the children from leaving the area. All play equipment is in safe condition and free from sharp, loose or pointed parts and the areas around or under high climbing equipment has appropriate cushioned material that absorbs a fall. Shade and drinking fountains (2) are available in the play area. Children drink water whenever they are thirsty. Teachers supervise children at all times in the play area.

The classroom has ample age-appropriate toys that appear to be safe and in good condition. There are no bodies of water accessible to children in care. There are cubbies available for all children's personal possessions. Children in care do not take naps at the facility.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2023
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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: FUSD - CABRILLO STATE PRESCHOOL
FACILITY NUMBER: 010214464
VISIT DATE: 03/24/2023
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All required posted documents were present. Disaster/fire drills are conducted monthly by the main school, the last drill was conducted on February 28, 2023. The classroom has two separate bathrooms with hot and cold running water. One bathroom is for the children, the other one is for staff. All toilets, handwashing and cleaning areas are in safe and sanitary operating condition. Trash bins were covered with tight fitting lids and all surfaces accessible to children are clean and toxic free. The sign in/out process is electronic. The process was reviewed and all children were properly signed in and accounted for. The snack menu is posted and visible for review. All food/snacks were within expiration date.

LPA reviewed children's records: LPA Haderer requested and reviewed the facility roster, a copy was taken. One child’s file was missing the LIC627 Consent for Emergency Medical Treatment – see LIC809D for deficiency. All other files selected were complete, up to date and found to be in compliance with Title 22 and Title V regulations.



LPA reviewed staff files. All files checked were complete, up to date and found to be in compliance with Title 22 and Title V regulations. LPA reminded site supervisor of the following: Mandated Reporter training (AB1207) and CPR/First Aid must be renewed every two years.

Site supervisor was reminded that all adults 18 and over, 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.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226.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



No children currently enrolled require any IMS service.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023
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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: FUSD - CABRILLO STATE PRESCHOOL
FACILITY NUMBER: 010214464
VISIT DATE: 03/24/2023
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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/inspection-process.

There was one deficiency issued today for a signed consent for emergency medical treatment. See LIC809D for Deficiency.



A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the site supervisor Brenda Bethancourt.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 03/24/2023 04:15 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612


FACILITY NAME: FUSD - CABRILLO STATE PRESCHOOL
FACILITY NUMBER: 010214464

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101221(b)(8)(C)
Child's Records
(C) A signed consent form for emergency medical treatment unless the child's authorized
representative has signed the statement specified in Section 101220(f).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that one of ten children's files checked was missing the LIC627 Consent for Emergency Medical Treatment which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2023
Plan of Correction
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Site supervisor to have parent complete and sign LIC627 form and provide proof to LPA.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5