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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410500494
Report Date: 03/23/2022
Date Signed: 03/23/2022 04:13:09 PM


Document Has Been Signed on 03/23/2022 04:13 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:PACIFICA PLAYSCHOOLFACILITY NUMBER:
410500494
ADMINISTRATOR:WHEELER, SUZANNEFACILITY TYPE:
850
ADDRESS:630 HICKEY BLVDTELEPHONE:
(650) 359-5673
CITY:PACIFICASTATE: CAZIP CODE:
94044
CAPACITY:44CENSUS: 44DATE:
03/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:11 AM
MET WITH:Sarah Scott and Suzanne WheelerTIME COMPLETED:
02:16 PM
NARRATIVE
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On March 23, 2022 at 11:11 AM, Licensing Program Analyst (LPA) Cowan met with teacher Sarah Scott for a 1 Year Required Inspection. The purpose of the inspection is explained and LPA is granted access to the facility. Upon arrival, the director was not present and teacher Sarah Scott inspected the facility with LPA. The director is not in the office upon arrival but arrives at 11:23 AM to complete the inspection with LPA. Present, in the facility are director, 5 staff, and 44 children in care. Facility is operating within its capacity, and facility is in compliance with staff / child ratio on this day. Facility operates day care Monday to Friday from 07:30 AM to 05:30 PM.

LPA toured facility with lead teacher and site director. LPA inspected the day care rooms and play yard. LPA observed facility has smoke detector, carbon monoxide detector, fully charged fire extinguisher and working telephone on site. All cleaning solutions, poisons and other chemicals dangerous to the children are stored inaccessible to the children. Facility has age appropriate furniture. Facility floor is in good repair and free of any hazards.

There are first aid supplies available in the classrooms. All bathrooms are in working condition. All storage containers for solid waste fitted lids. All food is stored properly to avoid contamination. Food preparation area is free of litter. Food is stored adequately to prevent contamination. Play yard is free of hazards. There is a sufficient amount of bark in the play yard to help absorb the impact of falls. There is water available on the yard as well as in the classroom.
Report continues on next page……….
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: April CowanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2022
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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Document Has Been Signed on 03/23/2022 04:13 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: PACIFICA PLAYSCHOOL
FACILITY NUMBER: 410500494

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type B
Section Cited
CCR
101216(g)(1)
Personnel Requirements
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in [1] out of [5] [(staff] [files] which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/30/2022
Plan of Correction
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Director agrees to email LPA a copy of staff LIC 503 Health screening by 4-30-22.
Deficiency Dismissed
Type B
Section Cited
CCR
101217(a)(12)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) Tuberculosis test documents as specified in Section 101216(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (record review), the licensee did not comply with the section cited above in [1] out of [5] staff files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/30/2022
Plan of Correction
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Director agrees to email LPA a copy of staff staff TB clearance by 4-30-22.

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: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: April CowanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2022
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: PACIFICA PLAYSCHOOL
FACILITY NUMBER: 410500494
VISIT DATE: 03/23/2022
NARRATIVE
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LPA observed the sign in / out sheet. PLA observed that parents are using full signatures. Facility has license and all other required documents posted and visible for the public. There are menus posted at least one week in advance and are visible to the child's authorized representative. Facility’s last emergency drill was conducted 3/18/22 and is properly logged.

At 11:54 AM, LPA reviewed the facility records. LPA reviewed 10 random children's files. Children’s files are complete with all required Licensing documents. LPA reviewed 5 staff files. At 12:10 PM, LPA observed that staff did not have Health Screening and TB clearance. These are potential risks to children in care. Type B citations are issued this day.

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 Family Child Care Homes Section 102417. 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.

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.
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: April CowanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
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: PACIFICA PLAYSCHOOL
FACILITY NUMBER: 410500494
VISIT DATE: 03/23/2022
NARRATIVE
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Director is aware that all staff is required to complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com. LPA observed the completion certificates on file. LPA encourages the director to frequently visit our website at www.ccld.ca.gov for licensing regulations and new updates.

>See next page for deficiencies

Exit interview conducted and report was reviewed with site director Suzanne Wheeler.

This report must be available in the facility for public review. Notice of site visit is to be posted for 30 days. Director was advised any additional questions to call Office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website: www.cdss.ca.gov

Copy of this report was reviewed and will be emailed to the director, Suzanne Wheeler at PACIFICAPLAYSCHOOL@COMCAST.NET by the close of business on 3/2/22. Confirmation of receipt is required. Signed copy of this report will be stored in the facility file.
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: April CowanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4