<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210110822
Report Date: 01/10/2020
Date Signed: 01/10/2020 03:47:49 PM

COMPREHENSIVE INSPECTION
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:ICE CREAM & SHOE PRESCHOOL & KINDERGARTEN INC.FACILITY NUMBER:
210110822
ADMINISTRATOR:RACZKA, SUSANFACILITY TYPE:
850
ADDRESS:1055 LAS OVEJASTELEPHONE:
(415) 492-0550
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:100CENSUS: 29DATE:
01/10/2020
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Susan RaczkaTIME COMPLETED:
04:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Farhan Bashir-Tariq met with Director, Susan Raczka, to conduct an Annual Inspection on 1/10/20. Purpose of the inspection was explained. Present, there were 29 children in care with five teachers and Director. Facility has five classrooms. LPA toured the classrooms with Director and observed that facility is operating within the capacity and is following staff child ratio on this day. Facility operates day care from Monday to Friday between 7:30 AM to 5:30 PM. Facility does not provide meals. Children bring their own meals and snacks. Snacks are provided occasionally if needed.

LPA and Director inspected the facility inside and outside. Per Director, there are no pools, spas or other bodies of water at the facility. Facility has smoke multiple detectors and fully charged fire extinguishers. There is a carbon monoxide detector and a working telephone available at the site. All of the cleaning solutions, poisons and other chemicals that are dangerous to the children are stored inaccessible to the children. Facility has age appropriate furniture. Furniture is steady and in good repair. Restroom are located outside in the play yard. There are separate restrooms available for boys and girls. All toilets, hand washing facilities are in working condition with proper sanitation in place. Facility has two play yards, one at front and one at the back. Play yards are free of hazards. All of the play structures are steady, in good repair and free of any loose parts. Artificial grass is installed under the play structures to prevent any fall injuries. Facility has drinking water available for the children. Per director, staff members bring water pitcher with drinking water and cup to the play yard.

LPA reviewed the facility records. LPA reviewed 8 random children's and 5 present staff's files. LPA observed facility has record of names, addresses and telephone numbers of each child's authorized representative. Each child's record contains the record immunization. Multiple staff members have record of valid CPR cards and Mandatory Child Abuse Training certificates in files. LPAs reviewed the educational qualification of all the teachers. Facility has a log for emergency drills being conducted. Per log, last emergency drill was conducted on December 11, 2019.
Continuation on next page...
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Farhan Bashir-TariqTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: ICE CREAM & SHOE PRESCHOOL & KINDERGARTEN INC.
FACILITY NUMBER: 210110822
VISIT DATE: 01/10/2020
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
This facility provides Incidental Medical Services – IMS. Medication are stored in the upper cabinet in Director's office. 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

During Inspection,
*Facility was reminded about having all Staff and Volunteers provide proof of immunization against influenza, pertussis, and measles or qualifies for an exemption.
*Site Director was reminded of Pesticides training. Information on the DPR website at: www.cdpr.ca.gov/shoolipm/childcare.
*Site Director was reminded about the Provider Information Notices (PINs) on CCLD website:www.ccld.ca.gov
*Site Director was reminded about of Mandated Reporter Training available on CCLD website: www.mandatedreporterca.com.


>No deficiencies were cited today under Title 22 Division 12 of the California Code of Regulations. This report and rights to comment and appeal were discussed with Director. This report must be available in the facility for public review. Notice of site visit shall be posted for 30 days from today's visit. Facility was advised for any additional questions to call Office, M - F, 8 AM-5 PM at 650-266-8800 . For Rules and Regulations, visit the Website: www.cdss.ca.gov
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Farhan Bashir-TariqTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2020
LIC809 (FAS) - (06/04)
Page: 2 of 2