414002154-1-29-2020-05-CC-ACON-BKWSAV-20200117124259

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414002154
Report Date: 01/17/2020
Date Signed: 01/29/2020 11:39:59 AM

COMPREHENSIVE INSPECTION

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 PRESCHOOL		FACILITY NUMBER:	414002154
ADMINISTRATOR:	ANGELA EUGENIO		FACILITY TYPE:	850
ADDRESS:	5066 PALMETTO AVENUE		TELEPHONE:	(650) 738-7463
CITY:	PACIFICA	STATE: CA	ZIP CODE:	94044
CAPACITY:	30	CENSUS: 23	DATE:	01/17/2020
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Angela Eugenio		TIME COMPLETED:	01:05 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	THIS IS AN AMENDED REPORT On January 17, 2020 at 9:15 AM, Licensing Program Analyst (LPA) April Cowan met with director for a random annual inspection. Purpose of the inspection was explained. Present, in the facility are director, 3 staff, 1 Parent volunteer, and 23 children in care. Facility is operating within the capacity and is in compliance with staff / child ratio on this day. Facility operates day care from Monday to Friday from 7:00 AM to 6:00 PM. 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. Furniture is in good repair. Facility floor is in good repair and free of any hazards. There are first aid supplies available in the classroom. All hand washing facilities are in working condition with proper sanitation in place. All storage containers for solid waste are in good repair and have proper lids. All food is stored in a properly manner and has lids to avoid contamination. Food is stored adequately to prevent contamination. Play yard is not in use today. Due to heavy rains yesterday, puddles are too deep for children to play. Director states that complete drainage usually take one day. Play yard has bark under play structure. There are menus posted at least one week in advance and are visible to the child's authorized representative. LPA observed that facility's sign in / out and has chart. Facility has license and all of the other required documents posted and visible for the public. See next page for continuation .........

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: April Cowan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2020

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 PACIFICA-FAIRMONT WEST PRESCHOOL	FACILITY NUMBER: 414002154
	VISIT DATE: 01/17/2020

NARRATIVE

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At 9:20 AM, LPA observed bedding from some child's cots touching bedding of other children's cots. LPA discussed sleeping equipment with director. Director state that bedding is washed by parents weekly and cots are cleaned weekly.
At 10:00 AM, LPA observed two teacher not on Facility Personnel Report. LPA discussed Personnel Report with director. Director stated that all teachers associations have been faxed to Regional Office.
At 10:22 AM, LPA reviewed the facility records. LPA reviewed 5 random children's and 3 random staff's files. Children's files are complete with all required documents.
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.

Incidental Medical Services (IMS) policy was discussed. Director gave to LPA a copy of Facility's IMS Policy. Director submitted an updated LIC 308, LIC 610, and LIC 500.

>>>>> Please see next page deficiency

This report must be available in the facility for public review. Notice of site visit was observed being posted. 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

The copy of this report is reviewed and provided to the director. Notice of site visit is posted and shall remain posted for next 30 days.

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: April Cowan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2020

LIC809 (FAS) - (06/04)

Page: 3 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: 01/17/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/17/2020 Section Cited	1 2 3 4 5 6 7	101170 (e) (2) Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: 2) Request a transfer of a criminal record clearance as specified in Section 101170(f) or This requirement is not met as evidenced by observation.
	8 9 10 11 12 13 14	Based on observation and record review, one staff is not associated to the licensee (City of Pacifica). This poses a potential risk to children in care. THIS IS AN AMENDED REPORT	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: April Cowan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2020

LIC809 (FAS) - (06/04)

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