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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414002154
Report Date: 06/13/2019
Date Signed: 06/13/2019 01:04:13 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 PACIFICA-FAIRMONT WEST PRESCHOOLFACILITY NUMBER:
414002154
ADMINISTRATOR:ANGELA EUGENIOFACILITY TYPE:
850
ADDRESS:5066 PALMETTO AVENUETELEPHONE:
(650) 738-7463
CITY:PACIFICASTATE: CAZIP CODE:
94044
CAPACITY:30CENSUS: 18DATE:
06/13/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Anglea EugenioTIME COMPLETED:
01:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Andrea Medlin met with director and staff for this random annual licensing visit. Purpose of visit explained. There are 18 children present. Teacher-child ratio is in compliance. Days and hours of operation: Monday through Friday 7:00AM-6:00PM. Physical plant toured to inspect for health and safety hazards. There is a fully charged fire extinguisher that meets minimum requirements, smoke detector, and a carbon monoxide (CO) detector in the facility. Children's bathroom inspected; all toilets and hand washing facilities are in safe and sanitary operating condition. Separate staff bathroom is available. No pools, spas, hot tubs, fish ponds, or similar bodies of water are present. Per staff, there are no firearms or weapons on site. Disinfectants, cleaning solutions, poisons and other items that are dangerous to children are inaccessible. Variety of age appropriate toys and materials for children are available. Classroom is set up for child care and furniture and equipment for children is present. Snacks and lunch are provided by the facility; sample menu is available and posted. Adequate first aid supplies are available. Sick children will be separated from the group while waiting for parents to pick up. Outdoor play area inspected for health and safety hazards. The areas around and under high climbing equipment is cushioned with tanbark. Outdoor activity spaces are enclosed by fences and surfaces are free of hazards. Facility has posted all the required licensing forms in a prominent accessible location. LPA reviewed staff and children's files. In the children’s files reviewed, each child had current immunization records and Parent's Rights (LIC995). In the staff files, each have verification of meeting the educational requirements except S2; all have health screening with TB test, required staff immunizations except S3 does not have the measels (MMR) immunization/immunity. All have verification of the mandated child abuse reporting training as compliant with AB1207. Director has current Pediatric First Aid and CPR certification (exp. 10/2020).
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Andrea MedlinTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
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 PACIFICA-FAIRMONT WEST PRESCHOOL
FACILITY NUMBER: 414002154
VISIT DATE: 06/13/2019
NARRATIVE
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Incidental Medical Services (IMS) policy discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA is 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. Facility informed that effective September 1, 2016, a person may not be employed or volunteer at a child care facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662. LPA reviewed with director the Mandated Child Abuse Reporting training as compliant with AB 1207. As of January 1, 2018 all child care staff and volunteers are required to complete Mandated Child Abuse Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com.

LPA advised staff to frequently visit the Department's website at www.ccld.ca.gov for licensing regulations and updates. Facility may email childcareadvocatesprogram@dss.ca.gov to be added to the email distribution list for licensing updates.

The deficiencies cited on the following pages are in violation of the California Code of Regulations, Title 22, Division 12, Chapter 1:

This report is reviewed with director and a copy of this report must be made available for public review upon request.



Notice of site visit posted and shall remain posted for 30 days.
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Andrea MedlinTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2019
LIC809 (FAS) - (06/04)
Page: 2 of 3
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 PACIFICA-FAIRMONT WEST PRESCHOOL
FACILITY NUMBER: 414002154
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/15/2019
Section Cited
HSC
1596.7995(a)(1)
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Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles.
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Facility will submit verification of measels (MMR) immunization or immunity for S2.

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This requirement is not met as evidence of S3 file review indicates no measels (MMR) immunization or proof of immunity. A negative reading for MMR indicates no immunity. This is a potential health and safety risk.
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Send proof of correction to the licensing office by 7/15/19.
Type B
07/15/2019
Section Cited
CCR
101216(b)
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Teacher Qualifications and Duties. Prior to employment a teacher shall meet the specified requirements.
This requirement is not met as evidence S2 file review is no verification of any educational info
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Facility will send verification of educational requirements to the licensing office by 7/15/19.
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To qualify as a teacher aide, an aide needs 3 ECE units and currently enrolled in 3 ECE units or 6 ECE units total. This is a potential health and safety risk.
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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: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Andrea MedlinTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2019
LIC809 (FAS) - (06/04)
Page: 3 of 3