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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410509300
Report Date: 09/11/2019
Date Signed: 09/11/2019 12:24:35 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:PACIFICA NURSERY SCHOOLFACILITY NUMBER:
410509300
ADMINISTRATOR:MILLER, CATHERINEFACILITY TYPE:
850
ADDRESS:548 CARMEL AVENUETELEPHONE:
(650) 355-4465
CITY:PACIFICASTATE: CAZIP CODE:
94044
CAPACITY:35CENSUS: 8DATE:
09/11/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Lorraine EnriquezTIME COMPLETED:
12:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Andrea Medlin met with staff for this random annual licensing visit. Purpose of visit explained. There are 8 children present during the visit. This facility operates as a co-operative arrangement. Days and hours of operation: Monday-Friday 8:30AM-3:30PM and operates in two sessions; a morning session and an afternoon session. The facility has fully charged fire extinguishers that meet the minimum requirements, smoke detectors, however there is no carbon monoxide (CO) detector in the facility. Children's bathrooms inspected; all toilets and hand washing facilities are in safe and sanitary operating condition. No pools, spas, hot tubs, fish ponds, or similar bodies of water are present. Per staff, there are no firearms or weapons on site. There is a small covered fish tank in the classroom with a snail and newt. Disinfectants, cleaning solutions, poisons and other items that are dangerous to children are inaccessible. Variety of age appropriate toys and materials for children is available. Classrooms are set up for child care and furniture and equipment for children is present. Adequate first aid supplies are available. Outdoor play area inspected for health and safety hazards. The areas around and under high climbing equipment is cushioned with tanbark; there is also a sand area for children. Outdoor activity space surfaces are free of hazards. Facility has posted all the required licensing forms in a prominent accessible location. Drinking water is available. LPA reviewed staff and children's files. In the children’s files, each child has current immunization records and Parent's Rights (LIC995). In the staff files, each have verification of meeting the educational requirements, health screening with TB test, required staff immunizations. Some staff are missing the mandated child abuse reporting training as compliant with AB1207.

(Continued on next pages 809-C and 809-D)
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8867
LICENSING EVALUATOR NAME: Andrea MedlinTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 4
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 NURSERY SCHOOL
FACILITY NUMBER: 410509300
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/11/2019
Section Cited

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Carbon monoxide detectors required; inspection. Every licensed child day care center shall have one or more carbon monoxide detectors in the facility.
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This requirement is not met as evidence there is no carbon monoxide (CO) detector in facility. This is a potential health and safety risk.
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Type B
10/11/2019
Section Cited

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Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles.
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This requirement is not met as evidence S1 does not have the required staff immunizations. This is a potential health and safety risk.
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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) 266-8867
LICENSING EVALUATOR NAME: Andrea MedlinTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2019
LIC809 (FAS) - (06/04)
Page: 3 of 4
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 NURSERY SCHOOL
FACILITY NUMBER: 410509300
VISIT DATE: 09/11/2019
NARRATIVE
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Incidental Medical Services (IMS) policy discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA is 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. Facility informed that effective September 1, 2016, a person may not be employed or volunteer at a child care facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662. LPA reviewed with director the Mandated Child Abuse Reporting training as compliant with AB 1207. As of January 1, 2018 all child care staff and volunteers are required to complete Mandated Child Abuse Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com.

LPA advised staff to frequently visit the Department's website at www.ccld.ca.gov for licensing regulations and updates. Facility may email childcareadvocatesprogram@dss.ca.gov to be added to the email distribution list for licensing updates.

The deficiencies cited on the following pages are in violation of the California Code of Regulations, Title 22, Division 12, Chapter 1:

This report is reviewed with staff and a copy of this report must be made available for public review upon request.

Notice of site visit posted and shall remain posted for 30 days
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8867
LICENSING EVALUATOR NAME: Andrea MedlinTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2019
LIC809 (FAS) - (06/04)
Page: 2 of 4
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 NURSERY SCHOOL
FACILITY NUMBER: 410509300
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/11/2019
Section Cited

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On and after January 1, 2018, a person who becomes an administrator or employee of a licensed child day care facility shall complete the mandated reporter training within the first 90 days of employment.
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This requirement is not met as evidence S1 and S2 do not have the mandated reporter training compliant with AB1207. This is a potential health and safety risk.
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For access to the training:

www.mandatedreporter.ca.com

A return visit will be conducted to verify correction.

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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) 266-8867
LICENSING EVALUATOR NAME: Andrea MedlinTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2019
LIC809 (FAS) - (06/04)
Page: 4 of 4