410517836-9-14-2022-05-CC-ACON-CJ9VQT-20220914163852

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 410517836
Report Date: 09/14/2022
Date Signed: 09/14/2022 04:39:04 PM

Document Has Been Signed on 09/14/2022 04:39 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-CENTRAL SITE		FACILITY NUMBER:	410517836
ADMINISTRATOR:	TEDFORD,TERRI&MEADE,DIANE		FACILITY TYPE:	840
ADDRESS:	525 MIDDLE ROAD		TELEPHONE:	(650) 593-4229
CITY:	BELMONT	STATE: CA	ZIP CODE:	94002
CAPACITY:	105	CENSUS: 69	DATE:	09/14/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:13 PM
MET WITH:	Katrina San Felipe		TIME COMPLETED:	04:55 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 14, 2022 at 2:13 PM, Licensing Program Analyst (LPA) April Cowan conducted an unannounced Annual Inspection and met with site director Katrina San Felipe. LPA disclosed the purpose the inspection and was granted entry into the facility. Present in the facility is site director and 7 staff supervising 69 children. The facility is operating on the grounds of Central Elementary School serving children K - 5th grades. The hours of operation are: Monday – Friday, 12:00 PM to 6:00 PM. Facility has a breakfast club on Thursdays 7:30 AM to 9:00 AM. With director, LPA inspected the day care rooms and play yard. LPA observed facility has smoke detector, carbon monoxide detector, 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. There are first aid supplies available in the classroom. All storage containers for solid waste fitted lids. 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 grass 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 Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: April Cowan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

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: SAN CARLOS-BELMONT AFTER SCHOOL-CENTRAL SITE	FACILITY NUMBER: 410517836
	VISIT DATE: 09/14/2022

NARRATIVE

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LPA reviewed sign in / out. LPA observed that parents are signing children out 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 8/24/22 and is properly logged. At 3:24 PM, LPA reviewed the facility records. LPA reviewed 10 random children's files. Children’s files are complete with all required Licensing documents. LPA reviewed 6 random staff's files which are also complete.

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 Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: April Cowan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

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-CENTRAL SITE	FACILITY NUMBER: 410517836
	VISIT DATE: 09/14/2022

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.

>No deficiencies were cited today under CCR, Title 22, Division 12, Chapter 3.

Exit interview is conducted, and report was reviewed with site director, Katrina San Felipe.
>This report and rights to comment and appeal were discussed with Licensee. This report must be available in the facility for public review. Notice of site visit is to be posted and shall remain posted for next 30 days.

Licensee 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

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

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: April Cowan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

LIC809 (FAS) - (06/04)

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