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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384001816
Report Date: 08/11/2022
Date Signed: 08/11/2022 03:00:15 PM


Document Has Been Signed on 08/11/2022 03:00 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/11/2022 02:58 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

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Licensing Program Analyst (LPA) Yee conducted a Required - 1 Year inspection today. The purpose of the inspection was explained. Present at the facility are 11 teachers and 46 children. Teacher to child ratios were met during today's visit. Days and hours of operation: Monday - Friday, xxx. The facility has fully charged fire extinguishers that meet the minimum requirements, smoke detectors, and a carbon monoxide detector. The program has waiver for the outside yard and posted.

LPA and Site director, Madonna toured and inspected the center for Health and Safety Hazards. Daycare areas: Prairie Dogs, Penguins, Pandas, Polar Bears, art room, music room, and outside yard. LPA observed outdoor equipment is in good condition, free from loose, sharp or pointed parts. There are no pools, spas or other bodies of water on the premises. All cleaning supplies and other potentially harmful items are made inaccessible to the children. Medications are stored in lock areas and made inaccessible to children. Furniture and equipment are in good condition. There are separate bathrooms on site for adults. Isolation for sick child is available. The facility provides morning snacks, lunch and afternoon snacks. The menu is posted. Drinking water is provided indoor and outdoor by individual labeled water bottles. Last Emergency Drill was conducted on 06/22/2022 and properly logged.

During the visit, LPA reviewed site director file and updated. However, recording keeping certificate was not available. Site director said she will locate her certificate and will submit to CCL by the end of this month.

During the inspection LPA reviewed 12 staff’ members files and in order. At least one staff have current Pediatric First Aid and CPR on file. Children files were reviewed and in order. Facility has posted all the required licensing forms in a prominent visible location.

LPA discussed Child Abuse Mandated Training AB1207 with the Site Principal. As of January 1, 2018 all staff will be required to complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com. All staffs have current AB1207 certificates.
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jennifer YeeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022
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: PACIFIC PRIMARY - ORANGE SUN CAMPUS
FACILITY NUMBER: 384001816
VISIT DATE: 08/11/2022
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Pesticide regulations were discussed with the Site Principal. In accordance with the Healthy Schools Act, California law requires that anyone using any pesticide must be trained every year in integrated pest management and the safe use of pesticides around children. The director was advised that a free one hour online course is available on the Department of Pesticide Regulation's Web site: www.cdpr.ca.gov/schoolipm/training. For questions, email ccipmlist@cdpr.ca.gov. All staff members have certificate.

This facility provides Incidental Medical Services-IMS. 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. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. 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

Facility was also informed that as of September 1, 2016, a person may not be employed or volunteer at a child care facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662.

LPA advised the facility to do a lead water testing if the building was built prior to 2010. The site director said they have a date scheduled already. The facility may find information under PIN 21021-CCP and 22-06-CCP.

Annual fees are current. During the visit, LPA obtained current LIC610, LIC309, LIC308. and LIC 500.

An Exit Interview was conducted with Site director. No deficiencies were issued today under Title 22 Division 12 of the California Code of Regulations. For updates on Licensing information, go to CCL website: www.ccld.ca.gov. For Provider Information Notice: ccld.ca.gov/PG5098.htm
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jennifer YeeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2