414001721-6-15-2021-05-CC-CINO-C3ZVJN-20210615162902

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414001721
Report Date: 06/15/2021
Date Signed: 06/15/2021 04:29:19 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:	CITY OF MENLO PARK-BELLE HAVEN SCHOOL-AGE CC PRGM		FACILITY NUMBER:	414001721
ADMINISTRATOR:	NATALYA JONES		FACILITY TYPE:	840
ADDRESS:	100 TERMINAL AVENUE		TELEPHONE:	(650) 330-2297
CITY:	MENLO PARK	STATE: CA	ZIP CODE:	94025
CAPACITY:	71	CENSUS: 0	DATE:	06/15/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Site Supervisor, Rondell Howard and Management Analyst II, Natalie Bonham		TIME COMPLETED:	02:30 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 Manager (LPM), Cindy Interiano conducted a Case Management inspection and met with Site Supervisor, Rondell Howard and Management Analyst II, Natalie Bonham. Purpose of the inspection was explained. Facility is currently licensed for 71 School Age children in rooms #1, 2, 3 and 4; however, facility is going through renovation, so the program has moved to Portable Building A (labeled 100A). Program will operate M-F, 8a-6p during summer camp and (some) non-school days, and M-F, 12p-6p, during the school district calendar. Site Supervisor, Management Analyst, and LPM inspected facility, indoors and outdoors, for Health and Safety hazards. Program operates in one large classroom. Kitchen, Office, and Storage Room are maintained off limits to children. Classroom has 2 restrooms, each with 1 sink and 1 toilet. Restrooms are maintained clean, in good repair, and with adequate supplies. Cleaning products and toxins are maintained inaccessible to children. Classroom has age appropriate toys and equipment for children. Classroom has proper ventilation and sufficient lighting. Room is equipped with an industrial fire alarm, a smoke and carbon monoxide detector, and a fully charged fire extinguisher. Program will have exclusive/scheduled use of sections of ‘Kelly Park,’ including the field/racetrack, Basketball court, and Tennis court. Children are not allowed to go beyond the set boundaries of the outdoor play area, unless supervised by a staff. Outdoor play area is free of debris and dangerous conditions. Additional shading will be placed in the outdoor play area. All outdoor toys and equipment are age appropriate and in good repair. Drinking water is readily available indoors and outdoors. Program serves daily snacks and are prepared in the Kitchen area. First Aid Kit and Emergency supplies are properly maintained and kept inaccessible to children. Designated area for an ill child is in the office and child's restroom will be disinfected after each use. Facility meets all the posting requirements. See Page 2. . .

SUPERVISOR'S NAME: Suzanne Roman-Clark	TELEPHONE: (650) 266-8823
LICENSING EVALUATOR NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021

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: CITY OF MENLO PARK-BELLE HAVEN SCHOOL-AGE CC PRGM	FACILITY NUMBER: 414001721
	VISIT DATE: 06/15/2021

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Page 2. . .

During the inspection, Site Supervisor, Management Analyst, and LPM discussed:
>Requirement to report any Unusual incidents (using the LIC 624)
>Incidental Medical Services (IMS) policy
>Individuals employed or volunteering at a child care facility must have proof of immunization: pertussis, measles and proof or declaration regarding influenza; or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662.
>Provider Information Notices (PINs) on CCLD website.
>Requirement for all staff to have Mandated Reporter Training, which is available on CCLD website and must be renewed every 2 years.
>LPM provided Technical Assistance for Covid-19 guidelines, including Social Distancing, proper use of PPE equipment, and cleaning / disinfecting / sanitizing of commonly used areas/items.

Prior to updating the license to reflect room change,
>Fire Clearance must be received

**No deficiencies were cited against the facility under CCR, Title 22, Div. 12, Ch. 1. **

>This report will be emailed to facility. This report must be available in the facility for public review. Any additional questions to call Office, M-F, 8a-5p, 650-266-8800 or 1-844-538-8766. Website: www.ccld.ca.gov

SUPERVISOR'S NAME: Suzanne Roman-Clark	TELEPHONE: (650) 266-8823
LICENSING EVALUATOR NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021

LIC809 (FAS) - (06/04)

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