384004423-7-23-2021-05-CC-GASL-C586XP-20210723211215

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 384004423
Report Date: 06/22/2021
Date Signed: 07/23/2021 09:12:34 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:	CCFC-GOLDEN GATE CENTER		FACILITY NUMBER:	384004423
ADMINISTRATOR:	DOROTHY LEE GRAHAM-GRANT		FACILITY TYPE:	850
ADDRESS:	1455 GOLDEN GATE AVENUE		TELEPHONE:	(415) 921-7019
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94115
CAPACITY:	18	CENSUS: 0	DATE:	06/22/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Fonda Davidson		TIME COMPLETED:	03:00 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) Glenn Schnell met with Applicant Fonda Davidson today for a pre-licensing inspection. This inspection included a technical assistance inspection for COVID-19 guidance and support. The applicant is requesting to change the capacity of the preschool application that was originally submitted and add a toddler option component to the program. Applicant now requests 20 children (ages 2 years to entry into first grade) and 12 children for the toddler option program ages 18 months to 36 months. Total capacity requested is 32. The applicant originally applied for an Infant license for 12 children at this same location, but wants to withdraw that applicant and convert the room to the toddler option component. The facility will operate Monday - Friday; 7:30 AM to 5:30 PM. The program is located on the property of Missionary Temple Christian Methodist Church and will be leasing space to operate at this location. The designated director/site supervisor for the facility is Dorothy Graham Grant. The facility was inspected today, indoor and outdoor, for health and safety hazards and measured to calculate capacity. Preschool Indoor: There is one classroom that will be used for the preschool program and the following square footage was calculated for the room: 832.071 sq ft. Total useable indoor square footage is 832.071 sq ft divided by 35 sq ft equals 23 children. The indoor space for children is observed today to be clean and all furnishing, toys and equipment observed to be safe and in good condition. There is storage space for children's personal belongings and cots to be utilized for napping children. The program will provide a sheet and blanket for their child, bedding will be laundered weekly at the facility. Cots will be cleaned at least weekly or more often if needed. Children will be signed in and out daily by manual signature. The indoor space is equipped with a fire extinguisher, smoke and carbon monoxide detectors, separate kitchen area where snack and lunch food is stored, garbage cans with tight-fitting lids, first aid and emergency supplies.

SUPERVISOR'S NAME: Ali Zebila	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Glenn A Schnell	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021

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: CCFC-GOLDEN GATE CENTER	FACILITY NUMBER: 384004423
	VISIT DATE: 06/22/2021

NARRATIVE

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There is a kitchen in the facility, however food for the children is prepared at a central kitchen and delivered to the facility daily. The program provides breakfast, lunch and snack daily. The facility is adequately ventilated and free of insects and bugs. A combination of disposable products and washable dishes and utensils will be used for food service. There is a dishwasher in the kitchen.

Medications will be stored in the kitchen inaccessible to the children; There are 2 toilets (30 capacity) and 4 sinks ( 60 capacity) accessible for children's use. Children's bathrooms are located in each classroom. The bathrooms were observed to be clean and with no health and safety hazards. There is a diaper changing table and sink in the preschool bathroom. Sinks accessible to children deliver water that is no warmer than 120 degrees. The program will provide pitcher of water and cups in the classroom 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 in the staff office and the adult bathroom will be used for an ill child.

Toddler Option Component Indoor Space. The following square footage was calculated for the room: 628.398 sq ft. Total useable indoor square footage for the toddler option room is 628.398 sq ft divided by 35 sq ft equals 17 children. The classroom is observed today to be clean and equipped with fire extinguisher, smoke and carbon monoxide detectors, cubbies for children's personal belongings, cots for napping, and age appropriate toys and equipment. All furnishing and equipment is observed to be safe and in good condition. There are garbage cans with tight fitting lids. The indoor space is equipped with a fire extinguisher, smoke and carbon monoxide detectors, first aid and emergency supplies. All sinks accessible to children deliver water no warmer than 120 degrees. There is a separate bathroom in the toddler option room with 1 sink (15 capacity) and 1 toilet (15 capacity) for children, and a diaper changing table and adult sink. There is 1 sink (15 capacity) in the classroom for children also.

SUPERVISOR'S NAME: Ali Zebila	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Glenn A Schnell	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021

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: CCFC-GOLDEN GATE CENTER	FACILITY NUMBER: 384004423
	VISIT DATE: 06/22/2021

NARRATIVE

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Outdoor Area for Toddler Option: The outdoor area measures 412.437 square feet allowing for 5 children. The applicant will also use the preschool outdoor space for additional space. Applicant understands that the toddler option children preschool children cannot commingle on the preschool outdoor space. Toddler option children under the age of 2 will be restricted from using the climber on the preschool playground due to manufacturers age limit restrictions. The outdoor area surface is observed to be clean, in good condition and physically separate from the preschool outdoor space. There is artificial grass turf that is padded underneath. There are no climbing structures on the toddler option outdoor space. A shade structure needs to be placed in the outdoor activity space. Drinking water will be made accessible to children outdoors with pitchers of water and cups.

Preschool Outdoor Area: The outdoor area measures 2737.35 sq ft. allowing for a total of 36 children. The outdoor area to be used is enclosed by at least a four foot fence and observed to be clean, safe and equipped with toys and equipment for children. Currently there is a climbing structure. There is an outdoor covered sand area. Pitchers of water and cups for drinking will be accessible to children outside. Shade for children will be provided by shade structure. The resilient material under the play structure is a combination pour and play and padded outdoor artificial grass. There are stairs leading into the church directly from the outdoor space. A portable barrier will be placed in front of the stairs to prevent access anytime children are present outside.

SUPERVISOR'S NAME: Ali Zebila	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Glenn A Schnell	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021

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: CCFC-GOLDEN GATE CENTER	FACILITY NUMBER: 384004423
	VISIT DATE: 06/22/2021

NARRATIVE

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The following items were reviewed as part of today's visit: Record keeping for staff, children and facility records, Care and Supervision of the Children, Child Discipline Procedures- staff will talk with the children and use redirection, Emergency Evacuation Procedures, Medication Policies, Isolation of Sick Children, Napping Requirements, Food Service, Transportation-none provided, Parents Rights, and Reporting Requirements. Required postings were observed during today's inspection. Facility will conduct monthly disaster drills and a log will be maintained for review upon request.

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 Title 22 Regulations 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

LPA Schnell reviewed the completed COVID-19 self assessment guide with the applicant. LPA also reviewed COVID-19 required postings. Applicant was informed that access to available Personal Protective Equipment (PPE) may be available through the local child care resource and referral agency.

Water testing for Lead requirement was discussed and applicant was advised that this requirement must be met by January 2023, and every five years thereafter.

Report was reviewed and signed by Fonda Davidson. Today’s report, 6/22/21, will be sent to Fonda Davidson at fdavidson@crossculturalsf.org by close of business, 6/22/21. Confirmation of receipt is required.

SUPERVISOR'S NAME: Ali Zebila	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Glenn A Schnell	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021

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: CCFC-GOLDEN GATE CENTER	FACILITY NUMBER: 384004423
	VISIT DATE: 06/22/2021

NARRATIVE

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LPA Schnell will recommend licensure of this facility for a capacity of 32 children, with no more than 12 being toddler option age, once the following is received. Items noted with an (*) will be required to be considered for a 90-day provisional license:
-*REVISED LIC 200A due to request to amend capacity and add toddler option component.
-*REVISED LIC 500- Staff for 32 full time children and show which staff positions will work with the toddler option children
-REVISED
-*FIRE CLEARANCE (STD 850) - Revised Request for inspection was sent 6/23/21.
-*REVISED LIC 401 DUE TO CAPACITY INCREASE
-FINANCIAL RELEASE AND VERIFICATION (LIC 404)- Need Wells Fargo Bank Verification Release Authorization form before. Return the original form for further processing to San Bruno Child Care Office as soon as possible.
-NEED CURRENT COPY OF TITLE 5 CONTRACT FOR ADDITIONAL VERIFICATION OF FUNDS.
-*DESIGNATION OF ADMINISTRATIVE RESPONSIBILITY (LIC 308)- Dorothy needs to complete this form and sign it designating another fully qualified teacher to act in her absence.
-*BYLAWS OF THE CORPORATION
-BALANCE SHEET (LIC 403)
-*PERSONNEL RECORD (LIC 501)- For Dorothy. Please submit an updated Personnel Record and complete the entire form. Refrain from stating "see attached" and including a resume.
-*HEALTH SCREENING REPORT (LIC 503) and immunization records (Tap, MMR, Influenza) for Fonda and Dorothy. A copy of the existing records on file are adequate.
-*EMERGENCY DISASTER PLAN (LIC 610)
-*VERIFICATION OF DIRECTOR QUALIFICATIONS- For Dorothy need proof of 16 hours Pediatric CPR/First Aid/Preventative Health Practices, mandated reporter training, pesticides training, and EMSA certified Lead Poison Training, LIC 501, LIC 508, LIC 503, LIC 9108. (Submitted training certificates for Dorothy do not qualify as acceptable training).

SUPERVISOR'S NAME: Ali Zebila	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Glenn A Schnell	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021

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: CCFC-GOLDEN GATE CENTER	FACILITY NUMBER: 384004423
	VISIT DATE: 06/22/2021

NARRATIVE

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-*ACKNOWLEDGEMENT TO REPORT SUSPECTED CHILD ABUSE (LIC 9108)- Needed for Fonda
-*ONLINE MANDATED REPORTER TRAINING- needed for Dorothy and Fonda
-PERSONNEL POLICIES
-IN-SERVICE TRAINING FOR STAFF
-PARENT HANDBOOK- In addition to previous revisions being requested, include adding details about the toddler option component in this handbook, and identify the age ranges for this program to be served (18 mo. to 36 mo.)
-DISCIPLINE POLICIES
-*ADMISSION POLICIES
-*ADMISSION AGREEMENT- in addition to previous revisions being requested, must include a statement that the parents are agreeing to have their child placed in the toddler option component.
-SAMPLE MENU
-LIST OF FURNITURE AND/OR PLAY EQUIPMENT
-*COVID-19 SELF-ASSESSMENT
-DAILY ACTIVITY SCHEDULE FOR THE TODDLER OPTION COMPONENT

SUPERVISOR'S NAME: Ali Zebila	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Glenn A Schnell	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021

LIC809 (FAS) - (06/04)

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