384004089-7-5-2019-05-CC-PHSH-BDSTBJ-20190705143514

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 384004089
Report Date: 07/03/2019
Date Signed: 07/05/2019 02:35:27 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

FACILITY NAME:	EXCELSIOR FAMILY CONNECTIONS		FACILITY NUMBER:	384004089
ADMINISTRATOR:	SIHAPANYA, YENSING		FACILITY TYPE:	850
ADDRESS:	5016 MISSION STREET		TELEPHONE:	(415) 333-3845
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94112
CAPACITY:	20	CENSUS:	DATE:	07/03/2019
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Tina Tam		TIME COMPLETED:	03:05 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Pandora Huffman-Smith met with the Education Director, Tina Tam, today for a pre-licensing inspection. The applicant was unavailable today due to previously scheduled appointment. The applicant is requesting 20 children (ages 3-5 years old). The facility is located in the rear of the Family Connections Resource Center and will operate Monday - Friday in two half day sessions; 9:00 AM to 12:00 PM and 12:30 PM to 3:30 PM. The facility was inspected today, indoor and outdoor, for health and safety hazards and measured to calculate capacity. Indoor: There is one classroom that will be used for the program that measures 818 square feet allowing for a capacity of 23 children. The classroom appears to be clean and all furnishing, toys and equipment appear to be safe and in good condition. The classroom is equipped with a fire extinguisher, smoke and carbon monoxide detectors, food prep area, first aid and emergency supplies. There is one bathroom for children's usage that is equipped with two toilets and two sinks. The bathroom appears to be clean and there are no apparent health and safety hazards. Total allowable capacity for toilets and sinks is 30. The program will provide a pitcher with water and cups for children to drink water indoors. All toxins and other hazardous items will be stored in a locked cabinet in the classroom and will be inaccessible to children. Isolation of ill children will be located either in a corner of the classroom or the directors office and staff bathroom will be used for the child until the parent arrives for pick up. Outdoor: The outdoor area measures 387 square feet allowing for a total of 5 children. LPA advised that a waiver will need to be approved for scheduled rotational usage. The outdoor area appears to be clean, safe and equipped with toys and equipment for children. There is a drinking fountain outdoor for children's usage. Continued on page 2

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Pandora Huffman-Smith	TELEPHONE: (650)266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 07/03/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2019

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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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: EXCELSIOR FAMILY CONNECTIONS	FACILITY NUMBER: 384004089
	VISIT DATE: 07/03/2019

NARRATIVE

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The facility will conduct monthly disaster drills and a log will be maintained for review upon request. The fire inspection was conducted and approval was received on June 24, 2019.

This facility will provide Incidental Medical Services – IMS. LPA reviewed storage area for medication and equipment/supplies, and reviewed forms that will be used. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226.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

A request for and approval of waiver for scheduled rotational usage of the outdoor play area is required prior to licensure,.

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Pandora Huffman-Smith	TELEPHONE: (650)266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 07/03/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2019

LIC809 (FAS) - (06/04)

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