414002281-2-1-2023-05-CC-CQUO-CNMSRH-20230201130622

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414002281
Report Date: 02/01/2023
Date Signed: 02/01/2023 01:06:53 PM

Document Has Been Signed on 02/01/2023 01:06 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	ROLLINGWOOD ELEMENTARY SCHOOL PRE SCHOOL		FACILITY NUMBER:	414002281
ADMINISTRATOR:	PAUAHI MCQINN		FACILITY TYPE:	850
ADDRESS:	2500 COTTONWOOD DRIVE		TELEPHONE:	(650) 624-3158
CITY:	SAN BRUNO	STATE: CA	ZIP CODE:	94066
CAPACITY:	14	CENSUS: 3	DATE:	02/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Teacher, Regina Herbert		TIME COMPLETED:	01:15 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	On February 1, 2023 at approximately 11:00am, Licensing Program Analyst (LPA) Catrina Quimbo conducted an unannounced, annual inspection at Rollingwood Elementary School in Preschool Portable Classroom #20. LPA met with teacher, Regina Herbert, and explained the purpose of the inspection. All staff working in classroom are fingerprint cleared through SB Park school district. Present during LPA's visit included 2 staff and 3 preschool children. Facility is operating within capacity limits and ratio during LPA's visit. Preschool program operates at Rollingwood Elementary School in Portable Classroom #20 only. Program operates in two part time sessions with a morning (8:00am to 11:00am) and afternoon (12:00pm to 3:00pm) program. LPA inspected the preschool classroom and outdoor area for health and safety hazards. LPA observed all licensing documentation and information is posted in the front entrance of the preschool classroom. Classroom is equipped with a fully charged fire extinguisher, working carbon monoxide detector and fully stocked first aid kit/emergency backpack and fire alarm system implemented by school district. Classroom has a working telephone on site. LPA observed all cleaning solutions, poisons and other chemicals are stored inaccessible to children in classroom's high shelves and/or locked behind child safety locked cabinets. Classroom is equipped with age appropriate furniture and materials that were in good working condition. Storage for children's belongings are located inside the classroom, labeled with children's individual names. Classroom is equipped with an accessible sink, free of poisons and hazardous materials. Classroom also includes one children's bathroom that was observed to be in proper working order. Bathroom is equipped with appropriate sanitation products. An additional cabinet is placed in bathroom that is used for storage purposes only. All accessible sinks in the classroom do not produce water that is warmer than 120 degrees Fahrenheit. Garbage bins in both classroom and bathroom were observed to have tight fitting lids. (Continue on Page 2....)

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8867
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023

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
PENINSULA CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ROLLINGWOOD ELEMENTARY SCHOOL PRE SCHOOL	FACILITY NUMBER: 414002281
	VISIT DATE: 02/01/2023

NARRATIVE

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Preschool program has an outdoor area that is separated from school district playground. LPA observed preschool program's outdoor area to be entirely enclosed with an at least 4 ft. high fence. Outdoor area was observed to be equipped with a variety of outdoor materials that were in good condition. Playground includes a play structure that was observed to have resilient padding underneath. Drinking water is available to children, indoors and outdoors, with children's individual drinking bottles and accessible water fountains.

Preschool program uses paper sign in/out system. LPA observed children are signed in and out of program with children's authorized representatives' written signatures. LPA reviewed 5 children's files and staff files. Children's and staff files were complete. Teacher on site has a valid CPR certification that will expire 05/2024.

Facility was informed that as of 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.

Teacher was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website atwww.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.
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SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023

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
PENINSULA CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ROLLINGWOOD ELEMENTARY SCHOOL PRE SCHOOL	FACILITY NUMBER: 414002281
	VISIT DATE: 02/01/2023

NARRATIVE

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Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was 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

No deficiencies were issued under CCR, Title 22, Division 12.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with teacher, Regina Herbert.

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023

LIC809 (FAS) - (06/04)

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