410509769-12-16-2022-05-CC-AMEN-CM734Y-20221216165555

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 410509769
Report Date: 12/16/2022
Date Signed: 12/16/2022 04:55:59 PM

Document Has Been Signed on 12/16/2022 04:55 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:	CSSF REC DEPT-SIEBECKER CENTER		FACILITY NUMBER:	410509769
ADMINISTRATOR:	ALENI CAPAZ		FACILITY TYPE:	850
ADDRESS:	510 ELM COURT		TELEPHONE:	(650) 875-6979
CITY:	SOUTH SAN FRANCISCO	STATE: CA	ZIP CODE:	94080
CAPACITY:	55	CENSUS: 22	DATE:	12/16/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Laura Armanino		TIME COMPLETED:	04:50 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	Licensing Program Analyst (LPA) Andrea Medlin met with facility representative required annual licensing visit today. Purpose of visit explained. There are 22 children present. Teacher-child ratio is in compliance. Days and hours of operation: Monday through Friday: 7:30AM-6:00PM. Physical plant toured to inspect for health and safety hazards. There are fully charged fire extinguishers that meet minimum requirements, smoke detectors, and a carbon monoxide (CO) detector. Children's bathroom inspected; all toilets and hand washing facilities are in safe and sanitary operating condition. A separate staff bathroom is available. No pools, spas, hot tubs, fish ponds, or similar bodies of water are present. Per staff, there are no firearms or weapons on site. Disinfectants, cleaning solutions, poisons and other items that are dangerous to children are inaccessible. Variety of age appropriate toys and materials for children are available. Classrooms are set up for child care and furniture and equipment for children is present. Cots are available for napping and are individually stored and labeled. Parent's provide the napping supplies and are responsible to wash once a week. Parent's provide meals; facility provides both morning and afternoon snack; sample menu is available and posted. Adequate first aid supplies are available. Sick children will be separated from the group while waiting for parents to pick up. Outdoor play area inspected for health and safety hazards. Outdoor activity spaces are enclosed by fences and surfaces are free of hazards. The areas around and under high climbing equipment is cushioned with tanbark. Facility has an outdoor playground waiver to use the adjacent public playground; facility has exclusive use during their outdoor play time. Facility has posted all the required licensing forms. LPA reviewed staff and children's files.In the children's files reviewed, all files are complete. In the staff files reviewed, all files are complete. In the children's files reviewed. Staff have the required immunizations: measels (MMR) and pertussis (Tdap). Staff have verification of the required mandated child abuse reporter training compliant with AB1207. (Continued on next page 809-C)

SUPERVISOR'S NAME: Daniel J Oquendo	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Andrea Medlin	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022

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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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: CSSF REC DEPT-SIEBECKER CENTER	FACILITY NUMBER: 410509769
	VISIT DATE: 12/16/2022

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.

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/process.

This report is reviewed with facility representative 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: Daniel J Oquendo	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Andrea Medlin	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022

LIC809 (FAS) - (06/04)

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