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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210102819
Report Date: 05/10/2023
Date Signed: 05/10/2023 04:48:53 PM


Document Has Been Signed on 05/10/2023 04:48 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
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:GOOD SHEPHERD LUTHERAN SCHOOLFACILITY NUMBER:
210102819
ADMINISTRATOR:JESSICA MCINTYREFACILITY TYPE:
850
ADDRESS:1180 LYNWOOD DRIVETELEPHONE:
(415) 897-2510
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY:122CENSUS: 40DATE:
05/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Jomana ShahinTIME COMPLETED:
05:03 PM
NARRATIVE
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On 5/10/2023, Licensing Program Analyst (LPA) Hanson Leong, made an unannounced annual visit to the child daycare facility listed above. The LPA was granted entry by the Interim Director (ID), Jomana Shahin. The LPA explained the purpose of the visit to the ID. One person out of the individuals listed on the facility's roster does not have permission to work or be present in a childcare facility. The remaining individuals all have permission to do so. The LPA observed seven staff members supervising forty preschool aged children. Children's capacity and ratio requirements were observed to be in compliance.

LPA and the ID both performed comprehensive inspections of the facility to look for possible threats to health and safety. The facility offers a first aid kit that is completely loaded with everything that is required for the treatment of wounds and other types of injuries. Toys, furnishings, and learning materials in all classes are age appropriate. The LPA observed that the playground equipment and outdoor furnishings are in very good shape. The LPA found that the facility did not have any pools, spas, or other types of bodies of water of any kind. All poisons, cleaning products, and other potentially harmful substances have been stored in a location that is inaccessible to children. The building is equipped with smoke detectors, carbon monoxide detectors, fire extinguishers that are properly charged, centralized smoke alarms, and phones that are in working order.

The ID has stated that the facility does not house any firearms or other types of weapons.

The LPA observed that the facility posted the required documents. (i.e., license, waivers, notification of parental rights, notification of personal rights, car seat law, emergency disaster plan, and daily activities)

The LPA reviewed the files of five different children. All required forms were in the files of the five children.

The LPA reviewed the files of five different staff members. All required forms were in the files of the five staff members. Review of the training records shows that none of the staff members completed their Pediatric First Aid / CPR training from an approved Emergency Medical Services Authority (EMSA) vendor. ***See Page 2 for continuation***

SUPERVISOR'S NAME: Daniel J OquendoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Hanson LeongTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023
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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Document Has Been Signed on 05/10/2023 04:48 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
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: GOOD SHEPHERD LUTHERAN SCHOOL
FACILITY NUMBER: 210102819

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101170(e)(1)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/11/2023
Plan of Correction
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The licensee will submit to the department a copy of the unfingerprinted individual's live scan form as well as a signed LIC 9224 from the parents of the children who are enrolled in the program.
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: Daniel J OquendoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Hanson LeongTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/10/2023 04:48 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
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: GOOD SHEPHERD LUTHERAN SCHOOL
FACILITY NUMBER: 210102819

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.16(a)(1)
Lead Testing
(1) A licensed child day care center, as defined in Section 1596.76, that is located in a building that was constructed before January 1, 2010, shall have its drinking water tested for lead contamination levels on or after January 1, 2020, but no later than January 1, 2023, and every five years after the date of the initial test.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to children in care.
POC Due Date: 06/10/2023
Plan of Correction
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The licensee will provide a completed LEAD water testing report to the department by the above date.
Type B
Section Cited
CCR
101216(f)
Personnel Requirements
(f) At least one staff member who is trained in pediatric cardiopulmonary resuscitation and pediatric first aid pursuant to Health and Safety Code Section 1596.866 shall be present when children are at the child care center or offsite for center activities.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2023
Plan of Correction
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The licensee will provide a copy of the interim director's or another staff's CPR / First AId card to the department by the above date.
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: Daniel J OquendoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Hanson LeongTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023
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
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: GOOD SHEPHERD LUTHERAN SCHOOL
FACILITY NUMBER: 210102819
VISIT DATE: 05/10/2023
NARRATIVE
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Continued, Page 2
The LPA reviewed the facility's emergency drill log. According to the facility’s emergency drill log, the facility's emergency drills are carried out monthly.

Based on record review and interview, the LEAD water testing was not completed, which is required for all licensed childcare facilities.

The Incidental Medical Services (IMS) policy was discussed with the ID. 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 the publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm



The ID 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 the 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.

The ID was informed about the Mandated Reporter training. In addition to AB1207 training required to complete every two years by all staff hired a one-time General Training is also required. Training can be taken online at www.mandaterreporterca.com. Also, the ID was reminded of Pesticide training. Information on the DPR website at: www.cdpr.ca.gov/shoolipm/childcare

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.

The following Type A violation (immediate health, safety, or personal rights risk to children in care) was cited for today’s visit: *** See Page 3 for continuation***
SUPERVISOR'S NAME: Daniel J OquendoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Hanson LeongTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
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
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: GOOD SHEPHERD LUTHERAN SCHOOL
FACILITY NUMBER: 210102819
VISIT DATE: 05/10/2023
NARRATIVE
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Continued, Page 3
1. CCR 101170(e)(1)- (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:
(1)Obtain a California clearance or a criminal record exemption as required by the Department or

Also, the LPA informed the licensee to provide a copy of this licensing report dated 5/10/2023 that documents any Type A citations to the parents or guardians of all children currently enrolled by the next business day or the next day the children are in care, and to the parents or guardians of any newly enrolled children for a period of 12 months from the date of this report. This information must be provided to the parents or guardians of any children who enroll after the date of this report. The next day that the children are in care is the cutoff for submitting this information before the deadline. The child's file needs to have either a signed Acknowledgement of Receipt of Licensing Report (LIC 9224) or another kind of written statement for the purposes of verification.

The following Type B violations (potential health, safety, or personal rights risk to children in care) were cited for today’s visit:

1. CCR 101216(f)- (f) At least one staff member who is trained in pediatric cardiopulmonary resuscitation and pediatric first aid pursuant to Health and Safety Code Section 1596.866 shall be present when children are at the child care center or offsite for center activities.

2. HSC 1597.16(a)(1)- A licensed child day care center, as defined in Section 1596.76, that is located in a building that was constructed before January 1, 2010, shall have its drinking water tested for lead contamination levels on or after January 1, 2020, but no later than January 1, 2023, and every five years after the date of the initial test.

***The department may clear all violations after the review of the facilities’ Plan of Correction***

A copy of this report, the “Notice of Site Visit”, and their appeal rights were given to Office Manager/HR, Lisa Herrmann. A “Notice of Site Visit”, and the Type A violation must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. An exit interview was conducted, and the report was reviewed with Lisa Herrmann

SUPERVISOR'S NAME: Daniel J OquendoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Hanson LeongTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5