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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410509433
Report Date: 04/06/2022
Date Signed: 04/06/2022 07:42:57 PM


Document Has Been Signed on 04/06/2022 07:42 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:SAN CARLOS-BELMONT AFTER SCHOOL; ARUNDEL SITEFACILITY NUMBER:
410509433
ADMINISTRATOR:BENEDICT, ELIZABETHFACILITY TYPE:
840
ADDRESS:200 ARUNDEL ROADTELEPHONE:
(650) 593-0707
CITY:SAN CARLOSSTATE: CAZIP CODE:
94070
CAPACITY:110CENSUS: 72DATE:
04/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:ELIZABETH BENEDICTTIME COMPLETED:
05:50 PM
NARRATIVE
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On April 6, 2022 at 2:25 PM, Licensing Program Analyst (LPA) Cowan met with director, Elizabeth Benedict, for a 1 Year Required Inspection. Purpose of the inspection was explained. Present, in the facility are director, 6 staff, and 70 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 06:00 PM. Facility operates on the grounds of Arundel Elementary School. Facility is operating out of only one of their licensed classrooms, 22A, for the time being.

With director, LPA inspected the day care room and play yard. LPA observed facility's smoke detector is integrated into in the school's main system. Facility has 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. At 3:28 PM, LPA observed that facility's carbon monoxide detector is not working. This is a potential risk to children in care. A type B citation is issued this day.

There are first aid supplies available in the classroom. All bathrooms are in working condition. 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: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2022
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 04/06/2022 07:42 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: SAN CARLOS-BELMONT AFTER SCHOOL; ARUNDEL SITE
FACILITY NUMBER: 410509433

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.954
Licensure Requirements
Every licensed child day care center shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (observation) the licensee did not comply with the section cited above in the carbon monoxide device did not work which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/20/2022
Plan of Correction
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Director agrees to email LPA a video of the demonstration of carbon monoxide device test.
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) 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. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

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 6 staff did not have immunization of file which poses a potential health, safety or personal rights risk to persons in care. Ref #4
POC Due Date: 04/20/2022
Plan of Correction
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Director agrees to email LPA a copy of immunuizations for Staff Ref 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 LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: April CowanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/06/2022 07:42 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: SAN CARLOS-BELMONT AFTER SCHOOL; ARUNDEL SITE
FACILITY NUMBER: 410509433

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

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 [5] out of [6] staff member did not have current Mandated Reporter Training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/20/2022
Plan of Correction
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Director agrees to email LPA a copy of current Mandated Reporter Training by 4-20-22.
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 [3] out of [6] staff files did not have TB clearances which poses/posed a potential health, safety or personal rights risk to persons in care. Ref # 4, 5, and 6.
POC Due Date: 04/20/2022
Plan of Correction
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Director agrees to email LPA a copy of TB clearances for staff by 4-20-22.

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: 04/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/06/2022 07:42 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: SAN CARLOS-BELMONT AFTER SCHOOL; ARUNDEL SITE
FACILITY NUMBER: 410509433

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(g)(2)
Personnel Requirements
(2) Each person specified in (g) above shall have a health-screening report signed by the person performing the screening. This report shall indicate the following:

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 [3] out of [6] staff files did not have health screenings which poses a potential health, safety or personal rights risk to persons in care. Ref # 4, 5, and 6
POC Due Date: 04/20/2022
Plan of Correction
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Director agrees to email LPA a copy of LIC 503 Health Screening for staff members.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: April CowanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2022
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: SAN CARLOS-BELMONT AFTER SCHOOL; ARUNDEL SITE
FACILITY NUMBER: 410509433
VISIT DATE: 04/06/2022
NARRATIVE
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LPA observed facility's sign in / out. LPA 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 3-15-22 and is properly logged. At 3:01 PM, LPA reviewed the facility records. LPA reviewed 10 random children's files. Children's files are complete with all Licensing documents. LPA reviewed 6 staff's files. At 3:28 PM, LPA observed that staff did not have immunizations on file. LPA observed that three staff did not have Health Screening of File and TB clearance on file. This is a potential risk 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 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

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: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022
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: SAN CARLOS-BELMONT AFTER SCHOOL; ARUNDEL SITE
FACILITY NUMBER: 410509433
VISIT DATE: 04/06/2022
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 the site director Elizabeth Benedict.

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, Elizabeth Benedict at AFTERSCHOOL@ARUNDEL.COMCASTBIZ.NET by the close of business on 4/6/22. 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: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022
LIC809 (FAS) - (06/04)
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