213004841-2-21-2023-05-CC-HLEG-CPA25H-20230221160535

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 213004841
Report Date: 02/21/2023
Date Signed: 02/21/2023 04:05:44 PM

Document Has Been Signed on 02/21/2023 04:05 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:	ABBEY MONTESSORI CHILDREN'S CENTER - INFANT		FACILITY NUMBER:	213004841
ADMINISTRATOR:	COSTELO, ELIZABETH		FACILITY TYPE:	830
ADDRESS:	138 N. SAN PEDRO ROAD		TELEPHONE:	(415) 479-8865
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	12	CENSUS: 7	DATE:	02/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Elizabeth Costelo		TIME COMPLETED:	04:20 PM

NARRATIVE

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On 2/21/2023, Licensing Program Analyst (LPA), Hanson Leong, made an unannounced annual visit to the Abbey Montessori Infant facility. The LPA was granted entry by the Director, Elizabeth Costelo. 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 two staff members supervising seven infants. Children's capacity and ratio requirements were observed to be in compliance,

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. The LPA noted that there were no bodies of water present at the facility. 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.

Two staff members’ files were reviewed by the LPA. All required forms were in the files of the two staff members. Review of the training records shows that one staff member is current with their Pediatric First Aid / CPR certifications. Review of the immunization records shows that one staff member is missing their immunization record. ***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: 02/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023

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: ABBEY MONTESSORI CHILDREN'S CENTER - INFANT	FACILITY NUMBER: 213004841
	VISIT DATE: 02/21/2023

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Continued, Page 2
According to the director, the facility satisfies the requirements by carrying out simulations of fire and earthquake drills every three to four months, 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. \
4. Regulations for safe sleeping in accordance with the Health and Safety Code. 5. Checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/
6. Requesting an exemption or waiver for sleep sacks

The following Type B violation (potential risks to the children in care) was cited for today’s visit):

1. Health and Safety Code 1597.622(a)(1)- Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

***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 Lourdes Anca

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 Lourdes Anca

SUPERVISOR'S NAME: Daniel J Oquendo	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Hanson Leong	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 02/21/2023 04:05 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: ABBEY MONTESSORI CHILDREN'S CENTER - INFANT	FACILITY NUMBER: 213004841
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.7995(a)(1)

General Provisions and Definitions

(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. 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 above, which poses a potential health, safety or personal rights risk to children in care.
	POC Due Date: 03/21/2023
	Plan of Correction
1 2 3 4	Director must submit a copy of the employees immunization record to the department 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: 02/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023

LIC809 (FAS) - (06/04)

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