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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414002661
Report Date: 10/17/2022
Date Signed: 10/17/2022 02:41:45 PM


Document Has Been Signed on 10/17/2022 02:41 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:SCSD HEATHER PRESCHOOLFACILITY NUMBER:
414002661
ADMINISTRATOR:DAVINO, JILLFACILITY TYPE:
850
ADDRESS:2757 MELENDY DRIVETELEPHONE:
(650) 508-7333
CITY:SAN CARLOSSTATE: CAZIP CODE:
94070
CAPACITY:60CENSUS: 31DATE:
10/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jill DavinoTIME COMPLETED:
02:55 PM
NARRATIVE
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On October 17, 2022 at 10:00 AM, Licensing Program Analyst (LPA) Cowan met with director, Jill Davino, for a 1 Year Required Inspection. Purpose of the inspection was explained. Present, in the facility is director, 6 staff, and 31 children in care. Facility is operating within its capacity, and facility is in compliance with staff / child ratio on this day. Facility operates day care Monday to Friday from 07:30 AM to 5:30 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. Facility floor is in good repair and free of any hazards.

There are first aid supplies available in the classroom. All bathrooms are in working condition. Facility has a sufficient amount of sleeping matts available. LPA inspected facility play yard. There is a sufficient amount of bark to help absorb the impact of falls. There is water available on the yard as well as in the classroom. At 10:17 AM, LPA observed that one child was with out supervision during capacity count. Staff promptly located child. This is a possible risk to children in care. A type B violation was issued this day for this deficiency.
Report continues on next page……….
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: April CowanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2022
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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Document Has Been Signed on 10/17/2022 02:41 PM - It Cannot Be Edited

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: SCSD HEATHER PRESCHOOL
FACILITY NUMBER: 414002661

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101229(a)(1)
Responsibility for Providing Care and Supervision
(a) The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (observation), the licensee did not comply with the section cited above in 1 out of 31 children was without supervision during capacity count which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2022
Plan of Correction
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Director agrees to train staff, provide LPA training points, and have attending staff sign showing attteandance.
Type B
Section Cited
CCR
101216(g)(1)
Personnel Requirements
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (record review), the licensee did not comply with the section cited above in 4 out of 5 staff did not have Health Screnings on file] which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2022
Plan of Correction
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Director agrees to collect health screnings from and email to LPA.

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 LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: April CowanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/17/2022 02:41 PM - It Cannot Be Edited

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: SCSD HEATHER PRESCHOOL
FACILITY NUMBER: 414002661

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101217(a)(12)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) Tuberculosis test documents as specified in Section 101216(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (record review), the licensee did not comply with the section cited above in 1 out of 5 staff did not have TB clearance on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2022
Plan of Correction
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Director agree to attain TB clearance documentation for ANN SCHWEIBINZ and email to LPA by above date.
Type B
Section Cited
CCR
101220(b)(1)
Child's Medical Assessments
(b) The medical assessment shall provide the following: (1) A record of any infectious or contagious diseases that would preclude care of the child by the licensee.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (record review), the licensee did not comply with the section cited above in 5 out of 5 children did not have a Health History on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2022
Plan of Correction
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Director agrees to collect Health History forms and email to LPA for DYLAN NGO, BOWEN SARIC, ABEL WONG, ELLIOT TSAI, and KATIE SHENG.

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 LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: April CowanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/17/2022 02:41 PM - It Cannot Be Edited

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: SCSD HEATHER PRESCHOOL
FACILITY NUMBER: 414002661

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101221(b)(6)
Child's Records
(b) Each record shall contain information including, but not limited to, the following: (6) A signed copy of the admission agreement specified in Section 101219.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (record review), the licensee did not comply with the section cited above in 5 out of 5 children did not have an admissions agreement on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2022
Plan of Correction
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Director agrees to collect agreements and email to LPA by above date for DYLAN NGO, BOWEN SARIC, ABEL WONG, ELLIOT TSAI, and KATIE SHENG.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: April CowanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2022
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: SCSD HEATHER PRESCHOOL
FACILITY NUMBER: 414002661
VISIT DATE: 10/17/2022
NARRATIVE
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LPA observed facility's sign in / out. LPA observed that parents are using full signatures. Facility has license and all other required documents posted and visible for the public. Facility’s last emergency drill was conducted 9/16/22 and is properly logged. At 11:12 AM, LPA reviewed the facility records. LPA reviewed 10 random children's files. At 11:20 AM LPA observed that children did not have Health History and Admission documents on file. This is a possible risk to children in care. Type B violations are issued for these deficiencies. LPA reviewed 5 random staff's files. At 12:14, LPA observed that staff did not have Health Screening and TB Clearance on file. Type B citations are issued for these deficiencies.

LPA discussed safety precautions on play yard with site director. LPA discussed the supervision of children, staff files, and facility furnishings with site director.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. 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

Facility has IMS policy of file with the Regional Office.
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: April CowanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022
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: SCSD HEATHER PRESCHOOL
FACILITY NUMBER: 414002661
VISIT DATE: 10/17/2022
NARRATIVE
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Director 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.

>See next page for deficiencies


Exit interview is conducted, and report was reviewed with site director, Jill Davino. Notice of site visit is to be posted and shall remain posted for next 30 days.

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

>This report and rights to comment and appeal were discussed with Licensee. This report must be available in the facility for public review.
Licensee 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
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: April CowanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022
LIC809 (FAS) - (06/04)
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