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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004003
Report Date: 02/16/2023
Date Signed: 02/16/2023 12:12:51 PM


Document Has Been Signed on 02/16/2023 12:12 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
PENINSULA CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:HAMILTON SHELTER PROGRAMFACILITY NUMBER:
384004003
ADMINISTRATOR:PETROVA, DIANAFACILITY TYPE:
840
ADDRESS:260 GOLDEN GATE AVENUETELEPHONE:
(415) 342-2203
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94102
CAPACITY:23CENSUS: 0DATE:
02/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Diana Petrova TIME COMPLETED:
12:15 PM
NARRATIVE
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 On February 16, 2023, Program Analyst (LPA) Van performed an unannounced mandated annual inspection and met with the Children's and Volunteer manager, Diana Petrova. The purpose of the inspection was explained to Ms. Petrova. This facility is a school-aged after-school program in a shelter building for children in 3rd – 8th grades. Days and operation hours are Monday - Friday from 3:00 pm to 6:00 pm. The Center uses the playroom on the second floor, the conference room on the 1st floor, and the dining room on the 4th floor. No children were present during LPA's inspection.
Ms. Petrova and LPA inspected the facility for potential health and safety hazards. All classrooms have age-appropriate games, books, and equipment in good repair. Classrooms have acceptable ventilation and ample lighting. LPA observed each child has cubbies with their name labeled. The facility has centralized smoke, carbon monoxide detectors, and a fully charged fire extinguisher. There are no pools, spas, or other bodies of water at the facility. All cleaning solutions, poisons, and other dangerous chemicals are stored in an area inaccessible to children. All the bathrooms, toilets, and sinks are clean and well-sanitized. All solid waste bins have a suitable tight-fitted lid on top, and the facility has water bottles stored in the refrigerator readily available for children. The outdoor playground area is located on the rooftop. LPA observed the playground to be in good repair and completely fenced for supervision. The play structure is age-appropriate and in good condition, with sufficient cushioning underneath.
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SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon VanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2023
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
PENINSULA CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: HAMILTON SHELTER PROGRAM
FACILITY NUMBER: 384004003
VISIT DATE: 02/16/2023
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 In today's inspection, LPA reviewed random samples of children's and staff records. Per Ms. Petrova, the teacher picks up the elementary school children upon parents' request and availability of the facility van, and the middle school children arrive independently. A head count will be conducted before entering the classroom. All children had a medical assessment, and the required licensing forms were completed. All staff has criminal record clearance. Teachers have records of valid Pediatric FirstAid/CPR cards in the file and the required immunization. LPA also observed that the facility had posted the required forms. (i.e., License, waivers, Notification of Parent's Rights, and Notification of Personal Rights). The Director stated that Fire and Earthquake drills are done at least once every six months, and the last drills were conducted on 2/3/2023.
LPA reminded the Director that as of September 1, 2016. A person may not be employed or volunteer at a childcare facility unless he or she has been immunized against influenza, pertussis, and measles. LPA observed that the facility has a record of required immunization of all staff.
The incidental Medical Services (IMS) policy was discussed. 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
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SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon VanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
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
PENINSULA CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: HAMILTON SHELTER PROGRAM
FACILITY NUMBER: 384004003
VISIT DATE: 02/16/2023
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The 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 a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.
The Director was informed about Mandated Reporter training available on the CCLD website. In addition to AB1207 training required to complete every two years by all staff hired, a one-time General Training is also required. Training can be taken online at www.mandaterreporterca.com. Also, the Director was reminded of Pesticides training. Information on the DPR website at: www.cdpr.ca.gov/shoolipm/childcare
To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.
During the inspection, LPA requested a new Emergency Disaster Plan (LIC 610), Designation of Responsibility (LIC 308), Personnel Report (LIC 500), and Basic Pest Management Training Certification for Director. All requested documents will be submitted to Licensing by February 17, 2023.
No deficiencies were cited today. An exit interview was conducted, and the report was reviewed with Ms. Petrova. Today's report and notice of the site visit were provided to Ms. Petrova. LPA informed Ms. Petrova that the site visit notice must be posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon VanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
LIC809 (FAS) - (06/04)
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