210110895-12-5-2019-05-CC-LGOZ-BJL2QU-20191205163630

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 210110895
Report Date: 12/05/2019
Date Signed: 12/05/2019 04:36:40 PM

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:	CITY OF SAN RAFAEL-MARY SILVERIA CHILDREN'S CENTER		FACILITY NUMBER:	210110895
ADMINISTRATOR:	BRODY, ANGELA		FACILITY TYPE:	840
ADDRESS:	375 BLACKSTONE		TELEPHONE:	(415) 485-3190
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94915
CAPACITY:	85	CENSUS: 52	DATE:	12/05/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Director, Angela Stunz		TIME COMPLETED:	04:45 PM

NARRATIVE

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Licensing Program Analyst, Luis J. Gomez made an unannounced annual inspection. LPA met with Director, Angela Stunz and explained the purpose of inspection. This is a school age, after-school program which operates at Mary Silveria Elementary School. Program utilizes 1 classroom: (Room 25) and the multi-purpose room. Hours of operation are Monday- Friday 1:50pm- 6:30pm. Present is the director and 3 staff supervising 52 children. Facility is operating within capacity limits of the license on this day. LPA inspected facility with director for health and safety hazards.

At 2:20pm on December 5, 2019 LPA inspected room 25. LPA observed classroom is clean, organized and have plenty of age appropriate toys, blocks art supplies and books for the children. The classroom has cubbies and several child size tables and chairs for activities. Classroom is equipped with several storage cabinet. LPA observed all trash cans and outlets are properly covered. There is a separate reading room and kitchen area located in the classroom. All hazardous items are stored inaccessible to the children. There has acceptable ventilation and natural lighting. The classroom has a smoke detector, carbon monoxide detector (located in the kitchen) and a fully charged fire extinguishers (3A40BC). First aid kit and an emergency disaster supplies are available by the front door.

At 3:00pm on December 5, 2019 LPA inspected multi-purpose room. LPA observed multi-purpose room is kept clean, free of debris and hazardous items. Per director, multi-purpose room is used primarily for group activities. Children’s restrooms are located in the hallway. Staff escorts children to the restroom to ensure supervision. Staff uses a separate restroom located in adjacent building. All children's medication, is current and stored inaccessible to the children.

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SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis Gomez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2019

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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: CITY OF SAN RAFAEL-MARY SILVERIA CHILDREN'S CENTER	FACILITY NUMBER: 210110895
	VISIT DATE: 12/05/2019

NARRATIVE

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5 children's files were reviewed. All children's files have the required emergency information and consent for medical treatment. Per, director program provided daily snack for children in care. Staff CPR/ first aid certification is current expiring: 02/2021. Emergency drills are done monthly, with the last drill conducted on, 10/28/2019, properly logged. LPA observed required licensing information is properly posted in facility.

Incidental Medical Services (IMS) was discussed. Licensee has no children who need services at this time. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding Americans with Disabilities Act (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: www.ada.gov/childqanda.htm.

During inspection,

· Director was reminded, as of September 1, 2016, all Staff and Volunteers must provide proof of immunization against pertussis, measles, and influenza, or qualifies for an exemption, pursuant to Health and Safety code 1596.7995 and 1597.662.
· Director was reminded about Mandated Reporter training available on CCLD website. Training must be completed every 2 years. Training can be taken online at www.mandatedreporterca.com
· Director was reminded about the Provider Information Notices (PINs) on CCLD website.
Licensee was advised for any additional questions to contact CCLD office, Monday to Friday, 8:00 am - 5:00 pm, (650) 266-8800 or 1 (844) 538-8766. Website: www.cdss.ca.gov

- Director provided updated LIC 308 during today's inspection

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SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis Gomez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2019

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: CITY OF SAN RAFAEL-MARY SILVERIA CHILDREN'S CENTER	FACILITY NUMBER: 210110895
	VISIT DATE: 12/05/2019

NARRATIVE

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Based on today's inspection, no deficiencies were observed in the areas evaluated according to the Title 22 Division 12 Ca. Code of Regulations. Exit interview was conducted with Director Angela Stunz, and her signature of this form acknowledges receipt of these documents.

>This report and rights to comment and appeal were discussed with Site Supervisor. This report must be available in the facility for public review. Notice of site inspection was posted.
Site Supervisor was advised any additional questions to call Office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website: www.ccld.ca.gov

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis Gomez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2019

LIC809 (FAS) - (06/04)

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