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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414001051
Report Date: 03/29/2021
Date Signed: 03/29/2021 12:02:32 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:PFS- HAVEN CDC (PS)FACILITY NUMBER:
414001051
ADMINISTRATOR:SHEPARD, TERIFACILITY TYPE:
850
ADDRESS:260 VAN BUREN AVENUETELEPHONE:
(650) 543-5210
CITY:MENLO PARKSTATE: CAZIP CODE:
94025
CAPACITY:24CENSUS: DATE:
03/29/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Site Supervisor-Teri ShepardTIME COMPLETED:
10:45 AM
NARRATIVE
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Licensing Program Analyst (LPA), Leslit Tapia-Mandujano, spoke with Site Supervisor, Teri Shepard via phone. Purpose of the call was explained and it was regarding CCLD (Community Care Licensing) receiving concerns over facility not reporting a positive Covid case in January 2021 and delayed reporting a second case in March 2021. Per CCLD’s investigation, it was determined Facility followed some but not all protocols in regards to Covid guidelines put in place by Public Health (PH), Center for Disease Control (CDC), and CCLD.

Facility has updated their protocols to include calling PH for any potential or confirmed case of Covid and follow PH’s recommendations/guidance. Site Supervisor was reminded to notify CCLD via phone call to CCLD within 24 hours of occurrence and LIC 624 (Unusual incident report) within 7 days of any potential/confirmed case of Covid in the facility, as well as any unusual incidents.

*** See attached page for deficiencies cited against the facility under CCR,Title 22, Div. 12, Chapt. 1. ***

>This report has been explained and discussed with the Site Supervisor via phone. Copy of report will be emailed and mailed to the facility. This report must be available in the facility for public review.
Site Supervisor was advised any additional questions to call Office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website: www.ccld.ca.gov
SUPERVISOR'S NAME: Cindy InterianoTELEPHONE: (650) 266-8864
LICENSING EVALUATOR NAME: Leslit Tapia-MandujanoTELEPHONE: (650) 350-2554
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2021
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: PFS- HAVEN CDC (PS)
FACILITY NUMBER: 414001051
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/29/2021
Section Cited

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101212(d) Reporting Requirements: Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event.
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This requirement was not met as evidence based on Facility not reporting incidents of two positive cases of Covid. This poses a potential safety risk to children in care.
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Site Supervisor submitted LIC 624.
Deficiency cleared.

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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: Cindy InterianoTELEPHONE: (650) 266-8864
LICENSING EVALUATOR NAME: Leslit Tapia-MandujanoTELEPHONE: (650) 350-2554
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2021
LIC809 (FAS) - (06/04)
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