410509152-5-21-2019-05-CC-GSIH-BCDVF3-20190521162315

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 410509152
Report Date: 05/21/2019
Date Signed: 05/21/2019 04:23:24 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:	WOODLAND SCHOOL		FACILITY NUMBER:	410509152
ADMINISTRATOR:	WILLIAMS, FELICITY		FACILITY TYPE:	850
ADDRESS:	360 LA CUESTA		TELEPHONE:	(650) 854-9065
CITY:	PORTOLA VALLEY	STATE: CA	ZIP CODE:	94028
CAPACITY:	45	CENSUS: 38	DATE:	05/21/2019
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Felicity Williams		TIME COMPLETED:	04:30 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) Singh met with the director, Felicity Willias, for a case management inspection for an incident. Purpose of the inspection was explained. Present, there are 38 children in care. The facility self reported that on May 7^th, 2019, a child was left in the play yard unsupervised. During today’s inspection, LPA interviewed the director. Per director, the facility takes the children to the play at 8:30 Am to 9:15 AM. Per director, facility keep the children in groups of their classroom. Per director, while the children are playing in the play yard, other children gets dropped at the facility. Director stated that on above mentioned date, all the children were playing in the yard. Per director, at 9:15 AM children were lined up in play yard and brought back into the classroom by two teachers. Per director, one of the child might have slipped out of the line and went behind the structure ‘house’. Per director, one the parent leaving in the parking lot observed the child in the play yard and did not observed any other child and teacher in the play yard. Per director, the parent came back into the facility and informed about the child to the staff. Per director, the child was brought back into the classroom by the teacher. Per director, the child was left alone from the time children were brought in until the leaving parent returned. Director stated that after the incident, director makes the checklist for every child being dropped off while other children are in play yard. Per director, before the teachers and children return to the classroom, teachers check the checklist to make sure every child is counted. Per director, teachers are doing more detail check to make sure all children get lined up to return into the classroom and director does the last check and go around every place in the play yard. See next page for continuation ...........

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Gagandeep Singh	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2019

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: WOODLAND SCHOOL	FACILITY NUMBER: 410509152
	VISIT DATE: 05/21/2019

NARRATIVE

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Continuation from previous page ..............

During the inspection, it was found that a child was left unsupervised for a short period of time. See next for deficiencies are cited today. The copy of this report is reviewed and provided to the director. Notice of site visit is posted and shall remain posted for next 30 days.

A Type “A” violation (see continuation) was issued today. The center is informed to provide a copy of the Evaluation Report and the Type “A” Deficiency cited to the parents and guardians of children currently enrolled in care and to parents of newly enrolled children during the next 12 months. A signed and dated LIC 9224 shall be maintained in all Children's files. This report and appeal rights were provided and reviewed with the licensee. Notice of Site Visit shall remain posted for 30 days.

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Gagandeep Singh	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2019

LIC809 (FAS) - (06/04)

Page: 3 of 3

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: WOODLAND SCHOOL	FACILITY NUMBER: 410509152
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/21/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/22/2019 Section Cited CCR 101229(a)(1)	1 2 3 4 5 6 7	101229(a)(1) Responsibility for Providing Care and Supervision: No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation. See below	1 2 3 4 5 6 7	Facility had made the checklist to confirm the children being brought into the classrooms after the play time. Per director, teachers and director is doing detailed checks before leaving the play yard. After consulting with licensing program manager, facility might be requested to join the informal meeting with the department.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by it was found a child was left unsupervised in the play yard, until a parent returned and informed the facility.This poses an immediate health and safety risk to children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Gagandeep Singh	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2019

LIC809 (FAS) - (06/04)

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