210110017-3-8-2023-05-CC-HLEG-CPR2JL-20230308162630

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 210110017
Report Date: 03/08/2023
Date Signed: 03/08/2023 04:26:35 PM

Document Has Been Signed on 03/08/2023 04:26 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:	FAIRFAX SAN ANSELMO CHILDREN'S CENTER-SCHOOL AGE		FACILITY NUMBER:	210110017
ADMINISTRATOR:	TOMSKY, HEIDI		FACILITY TYPE:	840
ADDRESS:	199 PORTEOUS AVENUE		TELEPHONE:	(415) 454-1811
CITY:	FAIRFAX	STATE: CA	ZIP CODE:	94930
CAPACITY:	65	CENSUS: 39	DATE:	03/08/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Heidi Tomsky		TIME COMPLETED:	04:41 PM

NARRATIVE

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On 3/8/2023, Licensing Program Analyst (LPA), Hanson Leong, made an unannounced annual visit to the Fairfax San Anselmo Children’s Center (School Age Program). The LPA was granted entry by the Director, Heidi Tomsky. The LPA explained the purpose of the visit to the director. All the individuals listed on the facility’s roster have been granted permission to work or be present in a childcare facility. The LPA observed five staff members supervising thirty-nine school age children. Children's capacity and ratio requirements were observed to be in compliance. During the visit, there was three dogs in the facility.

LPA and the director 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. 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 director 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).

Five different children's files were reviewed by the LPA. All required forms were in the files of the five children.

Five staff members' files were reviewed by the LPA. All required forms were in the files of the five staff members. Review of the training records shows that two staff members are current with their Pediatric First Aid / CPR certifications. ***See Page 2 for continuation***

SUPERVISOR'S NAME: Daniel J Oquendo	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Hanson Leong	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023

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
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: FAIRFAX SAN ANSELMO CHILDREN'S CENTER-SCHOOL AGE	FACILITY NUMBER: 210110017
	VISIT DATE: 03/08/2023

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Continued, Page 2
According to the director, the facility satisfies the requirements by carrying out simulations of fire and earthquake twice a year, as well as by documenting their results.

The following reminders were discussed with the director:

1. All adults 18 and over living or working in a licensed childcare facility, 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 licensed childcare facility.
2. Incidental Medical Services (IMS) policy
3. As of January 1, 2018, all staff must complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com.

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

1. Health and Safety Code 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 Heidi Tomsky. A “Notice of Site Visit” 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 the Director, Heidi Tomsky

SUPERVISOR'S NAME: Daniel J Oquendo	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Hanson Leong	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/08/2023 04:26 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: FAIRFAX SAN ANSELMO CHILDREN'S CENTER-SCHOOL AGE	FACILITY NUMBER: 210110017
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/08/2023

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
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited, which poses a potential health, safety or personal rights risk to children in care.
	POC Due Date: 04/08/2023
	Plan of Correction
1 2 3 4	Licensee will provide a copy of the LEAD water report or a waiver by the above due date

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Oquendo	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Hanson Leong	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023

LIC809 (FAS) - (06/04)

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