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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 213001117
Report Date: 08/21/2019
Date Signed: 08/21/2019 10:38:27 AM

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:JCC PRESCHOOL SAN RAFAELFACILITY NUMBER:
213001117
ADMINISTRATOR:RACHEL FALKFACILITY TYPE:
850
ADDRESS:200 N. SAN PEDRO ROADTELEPHONE:
(415) 444-8042
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:150CENSUS: 0DATE:
08/21/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Director, Rachel Falk TIME COMPLETED:
10:50 AM
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Licensing Program Analyst, (LPA) Luis J. Gomez met with director Rachel Falk. The purpose of today's inspection was explained and is in response to an incident that occurred on August 6, 2019. The incident involved a 4-year old child who fell and cut her forehead, requiring immediate medical attention. Present today is director and support staff. There are no children present during today's inspection.

At 9:20, on August 21, 2019 LPA Gomez inspected the outdoor play area for health and safety hazards. LPA Gomez observed the outdoor play area has floor padding and is free of debris, hazards or other dangerous conditions. LPA Gomez observed facility play structure, toys and equipment located in the outdoor play area are age appropriate and in good repair.
At 9:30am, on August 21, 2019 LPA Gomez interviewed the facility site Director. Director stated that (C1) fell and cut her forehead on the steps of the play structure, just above her right eyebrow, during the PreK's outdoor play time. Director stated that the teacher's responded to the incident right away, notifying her and providing First aid to the child's injury. Director stated the child's parents notified immediately, arriving to center within 20 minutes. Director stated she will continue to emphasize to her staff to be prepared and react accordingly when injuries occur on the play yard.

After meeting with meeting with director and inspection of the physical plant, it was determined that the incident was handled in an appropriate and timely manner.

Exit interview was conducted and a Notice of Site Visit was given.

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


SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8832
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 393-9134
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2019
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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