410509197-9-15-2022-05-CC-BVAN-CJASDD-20220915134657

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 410509197
Report Date: 09/15/2022
Date Signed: 09/15/2022 01:47:22 PM

Document Has Been Signed on 09/15/2022 01:47 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:	PENINSULA TEMPLE SHOLOM PRESCHOOL		FACILITY NUMBER:	410509197
ADMINISTRATOR:	STECKLEY, ALLISON		FACILITY TYPE:	850
ADDRESS:	1655 SEBASTIAN DRIVE		TELEPHONE:	(650) 697-2279
CITY:	BURLINGAME	STATE: CA	ZIP CODE:	94010
CAPACITY:	164	CENSUS: 111	DATE:	09/15/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Kim Gotthardt and Allison Steckley		TIME COMPLETED:	01:50 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	On September 15, 2022, Licensing Program Analyst (LPA) Van met with Administrator Kim Gotthardt for an unannounced annual random inspection. During the inspection, Site Director Allison Steckley arrived. The purpose of the inspection was explained and granted entry to the facility by the staff. The Center operates in classrooms 1 - 11, a library, and a multi-purpose room. Present today are 111 children supervised by 27 staff. The facility complies with the staff-children ratios today. The days and operations hours are Monday - Friday from 8:00 am to 6:00 pm. LPA toured and inspected the physical plant for any health and safety hazards. The facility utilizes an online app called Remini for sign-in /out for parents or authorized representatives; sign-in/out codes are provided to the parents. The facility is in good repair and has proper temperature and ventilation. Classrooms have age-appropriate toys and learning materials. Furniture appears steady and in good repair. The facility has multiple carbon monoxide detectors, a centralized smoke alarm, fully charged fire extinguishers, and working telephones. LPA observed that each child has their cubbies available with their name labeled. All emergency supplies are stored in locked storage. Medications are appropriately labeled and stored out of reach of children. First aid supplies are fully stocked and available for children's use. All cleaning solutions, poisons, and other dangerous chemicals are stored in an area inaccessible to children. Sleeping cots are appropriately stored. Continued on page 2...

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon Van	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

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 09/15/2022 01:47 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: PENINSULA TEMPLE SHOLOM PRESCHOOL	FACILITY NUMBER: 410509197
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Request Denied

Type A

Section Cited

CCR

101170(e)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interviews, and record review, S1 is an uncleared individual directly working with supervising enrolled children. This poses an immediate Health and Safety risk to persons in care.
	POC Due Date: 09/16/2022
	Plan of Correction
1 2 3 4	S1 left the Facility during LPA's visit. S1 will not return to work at the facility until fingerprint clearance is received.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon Van	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

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: PENINSULA TEMPLE SHOLOM PRESCHOOL	FACILITY NUMBER: 410509197
	VISIT DATE: 09/15/2022

NARRATIVE

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All toilets and handwashing facilities are in good operational condition and adequately sanitized. The facility currently has an outdoor waiver approved to allow 64 children to use outdoor play at a time. The outside play area is fully gated, sanitary, and in good condition. Outdoor play structures are appropriate for the age group, in great shape, and clear of loose components. Climbing structures are securely anchored, and all play structures have comfortable padding to absorb accidental falls. According to the Director, the sandboxes are checked daily before children play. LPA observed no bodies of water on the property.

The facility had posted the required forms. (i.e., License, waivers, Notification of Parent's Rights, Notification of Personal Rights, Car Seat Law, Emergency Disaster Plan, and Daily activities). Per the Director, the Center does not provide lunch or snacks, and families are required to bring their food. The facility has water readily available for children indoors and outdoors. All storage containers for solid waste within the Center have a proper tight-fitting cover.

Ten random children's records and personnel records were reviewed during the inspection. Records review showed the facility has records of each child's authorized representative's names, addresses, and telephone numbers. In addition, each child's immunization record, medical assessment, and admission agreement can be located in each child's file. Multiple staff members have a record of valid CPR. All staff maintained immunization records. LPA reviewed the educational qualification of the staff, and all staff had the required ECE units. The Director stated that the Center conducts fire and earthquakes monthly; the last drill was conducted on May 22, 2022. Since the new school year started on September 6, the facility has yet to conduct one.

During the teachers' record review, it was found that one of the teachers, S1, did not have fingerprint clearance. Per Director, S1 will have the livescan complete and will not return to the Center until the fingerprint is cleared.
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SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon Van	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

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: PENINSULA TEMPLE SHOLOM PRESCHOOL	FACILITY NUMBER: 410509197
	VISIT DATE: 09/15/2022

NARRATIVE

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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 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

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. In addition to AB1207 training required to complete every two years by the Licensee and 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

LPA encouraged the Director to visit the Licensing website at www.ccld.ca.gov for licensing regulations and new updates. Director can also email at childcareadvocatesprogram@dss.ca.gov and ask for the updates to be added to the email list.

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SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon Van	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

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: PENINSULA TEMPLE SHOLOM PRESCHOOL	FACILITY NUMBER: 410509197
	VISIT DATE: 09/15/2022

NARRATIVE

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During the inspection, LPA requested the following document be sent to the Licensing office by September 23, 2022.
1. an up-to-date Emergency Disaster Plan (LIC 610)
2. Personnel Report (LIC 500)
3. Designation of Administrative Responsibility (LIC 308).
4. Incidental Medical Services Plan
5. Updated Mandated reporter training for staff
6. Basic Pest Management Training completion for all staff

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/ection-process.

See next page for deficiencies cited. 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 Director. LPA informed the Director 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 Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon Van	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

LIC809 (FAS) - (06/04)

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