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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410517377
Report Date: 06/03/2019
Date Signed: 06/03/2019 04:18:31 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:CHILD DEV CTR-HENRY FORD CHILD DEVELOPMENT CENTERFACILITY NUMBER:
410517377
ADMINISTRATOR:REYNOLDS, DEANNE P.FACILITY TYPE:
840
ADDRESS:2498 MASSACHUSETTS AVENUETELEPHONE:
(650) 368-1138
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY:70CENSUS: 48DATE:
06/03/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Belen SalazarTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Singh met with the teacher, Belen Salazr, for a case management inspection for an incident that facility self reported. Purpose of the inspection as explained. Present, there are 48 children with four teachers.

The facility self reported that on May 09, 2019, a child was playing in the play yard and had injury by falling from a bar. During today’s inspection, LPA inspected the play yard. LPA observed that all play structures are steady and free of any loose parts. LPA observed the play structures are in good repair. During the inspection, the LPA interviewed the teachers, Carmen and Corrina, who witnessed the incident. Per teachers, there were four teachers present in the play yard at the time of incident. Per teacher Corrina, a child was playing at monkey bars and fell and landed on the elbow. Per Corrina, Corrina brought the child to the classroom and applied the ice. Per Corrina, Corrina called the parents and left the voicemail and parents returned the call later on same day. Per Corrina, the parent picked up the child and teacher informed the parent about the incident and asked to have the child checked by physician.

No violations of any regulations were observed. Copy of this report is reviewed and provided to the teacher. Notice of site visit is posted and shall remain posted for next 30 days.
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Gagandeep SinghTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2019
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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