410518991-12-16-2019-05-CC-MROZ-BJWQ3A-20191216104825

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 410518991
Report Date: 12/16/2019
Date Signed: 12/16/2019 10:48:32 AM

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 MATEO-FOSTER CITY SCHL DIST - NORTH SHOREVIEW		FACILITY NUMBER:	410518991
ADMINISTRATOR:	FORE, MELINDA		FACILITY TYPE:	850
ADDRESS:	1301 CYPRESS AVENUE		TELEPHONE:	(650) 312-7588
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94401
CAPACITY:	24	CENSUS: 24	DATE:	12/16/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Karrie Haselton		TIME COMPLETED:	11:00 AM

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) Marie Rodriguez conducted an unannounced Annual Random inspection. LPA met with Lead Teacher Hiromi Mead and explained purpose of inspection. Principal Karrie Haselton arrived a short time later. Center is a montessori program located in Room 20 inside of North Shoreview Montessori School. Present at center was the Principal, 1 lead teacher, 2 teacher assistants, and 24 children (Pre-K). Center is operating within capacity requirements and in compliance with child to staff ratio. Hours of operation are Monday to Friday from 8:30am to 3:00pm. LPA toured and inspected classroom 20. There are no bodies of water, firearms, or weapons on the premises. Classroom is in good condition with proper temperature and ventilation and are free of any hazards. Furniture in classroom is in good repair. Classroom has age appropriate toys and equipment. There is a fish tank, a hermit crab tank, and a stick bug tank for children's observation. All tanks are covered and inaccessible to children. There is one bathroom in the classroom with one sink and two toilets. There is an additional sink in the classroom with a water fountain that is available for children's use. Bathroom appears to be clean, in good repair, and free of any hazards. There is a separate bathroom for staff usage on the premises. The outdoor play area is fenced for supervision with age appropriate toys and equipment in good condition. Play structure is shared with the Kindergarten class and is in good repair with sufficient cushioning underneath. All required postings and waiver are posted on the bulletin board by the door of the classroom. Center only provides a morning snack. A menu is posted for the month. Food preparation area is clean and free of any toxins or contamination. All food is properly stored to avoid contamination. Drinking water is available for children indoor and outdoors. All storage containers for solid waste have a proper lid. All cleaning products, chemicals, and toxins are inaccessible to children. Incidental Medical Services (IMS) were discussed. There is an IMS plan in place but there are no children receiving services during this school year. (Continued on second page)

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Marie Rodriguez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2019

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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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 MATEO-FOSTER CITY SCHL DIST - NORTH SHOREVIEW	FACILITY NUMBER: 410518991
	VISIT DATE: 12/16/2019

NARRATIVE

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(Continued from first page)

Last emergency drill was conducted in November 2019. Emergency drills are conducted on a monthly basis in conjunction with the school's emergency drill schedule and are properly logged. The center has a complete record of sign-in/out sheets by authorized pickup person. There is a working fire alarm system connected to the school, a fully charged fire extinguisher, a smoke and carbon monoxide detector, and a working telephone available on site. Phone number listed on license is current.

Five children records reviewed were complete. All children have a record of emergency identification information on file. Three staff records reviewed were complete. All staff have a criminal record clearance on file through the school district. Staff have current Pediatric First Aid/CPR certificates and Mandated Reporter training certificates on file..

During inspection,

Principal was given information regarding Technical Support Program and Lead Poisoning Facts.
Principal was reminded, as of September 1, 2016, all Staff and Volunteers must provide proof of immunization against pertussis, measles, and influenza, or qualifies for an exemption, pursuant to Health and Safety code 1596.7995 and 1597.622.
Principal was reminded about Mandated Reporter Training. Training must be completed by staff every two years. (Website: www.mandatedreporterca.com).
Principal was reminded about the Provider Information Notices (PINs) on CCLD website.

No deficiencies cited today.

This report was reviewed and discussed with Principal Karrie Haselton. A copy of report was provided.
Notice of site visit was observed being posted and shall remain posted for 30 days.

For any additional questions, call San Bruno CCLD Office, Monday - Friday, 8am - 5pm, (650) 266-8800 or 1 (844) 538-8766. Website: www.cdss.ca.gov.

The following forms are to be updated and submitted to CCLD by January 6, 2020:
LIC 308 – Designation of Administrative Responsibility
LIC 309 - Administrative Organization
LIC 500 – Personnel Report
LIC 610 - Emergency Disaster Plan

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Marie Rodriguez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2019

LIC809 (FAS) - (06/04)

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