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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380504984
Report Date: 03/24/2022
Date Signed: 03/24/2022 02:27:58 PM


Document Has Been Signed on 03/24/2022 02:27 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:KATHERINE MICHIELS SCHOOLFACILITY NUMBER:
380504984
ADMINISTRATOR:ZELLERBACH, LAURA ROSEFACILITY TYPE:
830
ADDRESS:1335 GUERRERO STREETTELEPHONE:
(415) 821-0130
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94110
CAPACITY:15CENSUS: 11DATE:
03/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Yolanda AnchetaTIME COMPLETED:
02:40 PM
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On 3/24/2022 at 8:50A.M., Licensing Program Analyst, Luis J. Gomez met with Director, Yolanda Ancheta. Purpose of the inspection was explained and was for an Unannounced Annual/ Random inspection. Facility is a combination center with a preschool program on-site. Present was director and 4 staff supervising 11 children. Children had been properly signed-in. Facility was operating within capacity limits of the license on this day. All staff present had their criminal record clearance of file with the department. Infant program utilizes one classroom, napping room and one, shared, outdoor play space. Hours of operation are Monday- Friday 8:00am- 6:00pm. Program operates year-round. LPA inspected facility, indoors and outdoors, with director for health and safety hazards.

At 9:10A.M., LPA observed the following: Infant classroom was clean and organized with plenty of age-appropriate toy and playthings for the children. Floors and ground surfaces were free of potential hazards. Infant classroom had been separated into several activity areas which include: Recreation Area, Lunch Area and Potty Area. Facility had at least one potty chair for every five toilet-training infants in care. Classroom had individualized hangers and shelving for storage of children’s belongings. Classroom was equipped with diaper changing table within arm’s reach of a sink.

At 9:30A.M. Based on observations, LPA confirmed playroom had exposed sink piping accessible to children in care. During inspection, Advisory Note: Technical Violation (LIC9102) was issued.



Food preparation area was equipped with a refrigerator and several bottle warmers. LPA observed children’s milk and food items had been properly stored and labeled with their name and the date. For napping services, each infant in care had their own labeled crib /cot, with tight fitting sheet. Infant cribs had visible sides for constant staff supervision. Per Director, children’s napping linins and sheets are washed daily.

At 9:35A.M. Based on observations and interviews, LPA confirmed an unapproved napping space had been added to the on-limit area. Per director, space was added for better social distancing during nap time. (REFER TO 809C FOR CONT.)

SUPERVISOR'S NAME: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2022
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: KATHERINE MICHIELS SCHOOL
FACILITY NUMBER: 380504984
VISIT DATE: 03/24/2022
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Classroom/ napping room had acceptable ventilation and lighting. All trash bins, outlets have been properly covered. LPA observed accessible children's sink was in operating condition with adequate supplies. Staff restroom was located in facility hallway. Detergents, cleaning supplies and sharp objects were made inaccessible. Classroom had a smoke/ carbon monoxide detector combo and a fully charged fire extinguisher (3A:40BC).

At 9:50A.M., LPA inspected the outdoor play area. LPA observed area was completely enclosed with tall fencing. Area was clean and free of debris or other hazardous items. Play items inspected were in like-new condition and the play structure was properly anchored. Water service is provided using refillable water bottles. LPA observed shaded rest/ seating area available for children.

At 9:52A.M., Based on interview and observations, LPA confirmed infant outdoor play space not located physically separate from preschools. During inspection Advisory Note: Technical Violation (LIC9102) was issued.

At 10:30A.M., During inspection, LPA conducted facility record review. Record review included 10 children’s files and 4 personnel. Staff files reviewed were complete with current Mandated Reporter Training Certification, Required Immunization, Proof of Education, Notice of Employee Rights (LIC9052) and Criminal Record Statement (LIC508).

Present staff member had their current cardiopulmonary resuscitation/ first aid certification on file which expires: 10/2022.

Children files were reviewed were complete. Files included children's Infant Needs and Services Plan, Consent for Medical Treatment (LIC627), Identification of Emergency Information (LIC700), Updated Immunization Records, Admissions Agreement and signed Individual Infant Sleeping Plan (LIC9227) for qualifying infant in care.

Facility is maintaining required napping logs for children under 24 months of age.

Emergency drills are being conducted in the facility every six months. Last drill done on, 11/16/2021, properly logged. Per director, parents provide all daily snack and meals. All required posting were observed in facility.

LPA reminded director ensure all posting are posted in location that is visible to the parents/ authorized representatives. (REFER TO 809C, FOR CONT.)

SUPERVISOR'S NAME: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022
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: KATHERINE MICHIELS SCHOOL
FACILITY NUMBER: 380504984
VISIT DATE: 03/24/2022
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Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manuel – Regulations Interpretations and Procedures for Child Care Centers Section 101173 and 101226. When an IMS is provided, an updated Plan of Operations that includes IMS must be submitted to the Department. Following information regarding ADA was provided: US Department of Justice (USDOJ) toll- free ADA information line at (800) 514- 0382 (TTY) and link to publications: Commonly asked questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

Director was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in Child Care Center. A civil penalty of $100.00 minimum/ day up to $500.00 maximum per day/per person will be assessment if this regulation is violated.

LPA discussed safe sleep regulations with the director and discussed Child Care Licensing Safe Sleep webpage at http://www.cdss.ca.gov/inforesource/child-care-licensing/public-information-and-resouce/safe-sleep as an additional resource. LPA also informed director of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at: http://www.cpsc.gov/ and recommend they register all infant devices with the CPSC to be notified of any recalls on their purchased requirement.

Based on today's inspection, deficiencies were observed in the areas evaluated according the Title 22 Division 12 Ca. Code of Regulations. Exit interview, plan of correction and evaluation report was reviewed with director, Yolanda Ancheta and signature of this form acknowledges receipt of these documents.



This report and rights to comment were discussed. This report must be available in the facility for public review. Notice was given and must remain posted for 30 days. Facility 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: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 03/24/2022 02:27 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: KATHERINE MICHIELS SCHOOL

FACILITY NUMBER: 380504984

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 03/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101212(c)
101212(c) Reporting Requirment: The licensee shall notify the Department in writing of his/her intent prior to making any structural changes that reduce the total amount of indoor or outdoor activity space. Such structural changes shall include, but not be limited to, room additions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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At 9:35A.M. Based on observations and interviews, LPA confirmed an unapproved napping space had been added to the on-limit area. This poses a potential health and safety risk to children in care.
POC Due Date: 04/08/2022
Plan of Correction
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Director will submit updated Facility Sketch, (LIC999) with signed letter of intentions to the department by the due date. Subsequent case management inspection will be conducted by LPA.

Director will submit proof of correction to the department via email.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4