414002663-9-6-2022-05-CC-ACON-CHZUQK-20220906154716

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414002663
Report Date: 09/06/2022
Date Signed: 09/06/2022 03:47:32 PM

Document Has Been Signed on 09/06/2022 03:47 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:	IMMACULATE HEART OF MARY (PRESCHOOL)		FACILITY NUMBER:	414002663
ADMINISTRATOR:	ARBAN, ERSIE		FACILITY TYPE:	850
ADDRESS:	1000 ALAMEDA DE LAS PULGAS		TELEPHONE:	(650) 593-4265
CITY:	BELMONT	STATE: CA	ZIP CODE:	94002
CAPACITY:	36	CENSUS: 7	DATE:	09/06/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Ersie Arban		TIME COMPLETED:	04:10 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 September 6, 2022 at 12:30 PM, Licensing Program Analyst (LPA) Cowan met with director for a 1 Year Required Inspection. Purpose of the inspection was explained. Present in the facility are director, 2 staff, and 7 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 07:45 AM to 06:00 PM. When LPA arrived, children were napping. At 12:40 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. Food preparation area is free of litter. Food is stored adequately to prevent contamination. Play yard is free of hazards. 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. Report continues on next page……….

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: April Cowan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2022

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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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: IMMACULATE HEART OF MARY (PRESCHOOL)	FACILITY NUMBER: 414002663
	VISIT DATE: 09/06/2022

NARRATIVE

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LPA observed facility's sign in / out sheet. LPA observed that parents are using full signatures. Facility has license and all other required documents posted and visible for the public. There are menus posted at least one week in advance and are visible to the child's authorized representative. Facility’s last emergency drill was conducted 8/25/22 and is properly logged. At 1:27 PM, LPA reviewed the facility records. LPA reviewed 7 random children's files. Children’s files are complete with all required Licensing documents. LPA reviewed 2 staff's files. At 1:30 PM, LPA observed that a staff member did not have LIC 503 Health Screening, TB Clearance, nor updated Mandated Reporter Training on file. This is a potential risk to children in care. LPA issued Type B citations for these deficiencies.

LPA discussed staff files with site director. LPA discussed Emergency Drills, Covid-19 Protocols, and placement of sick children with site director.

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

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.

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: April Cowan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2022

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: IMMACULATE HEART OF MARY (PRESCHOOL)	FACILITY NUMBER: 414002663
	VISIT DATE: 09/06/2022

NARRATIVE

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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.

>See next page for deficiencies

Exit interview is conducted, and report was reviewed and given to site director. 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

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: April Cowan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/06/2022 03:47 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: IMMACULATE HEART OF MARY (PRESCHOOL)	FACILITY NUMBER: 414002663
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.7995(a)(1)

General Provisions and Definitions

(1) 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. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on (record review), the licensee did not comply with the section cited above in 2 out of 2 staff members did not have Immunizations of file ( Alicia Villa and Grace Alderguer) which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/16/2022
	Plan of Correction
1 2 3 4	Director agrees to collect immunizations from staff members and email to LPA by 9/16/22.

Type B

Section Cited

HSC

1596.8662(b)(1)

Administration of Child Day Care Licensing

(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on (record review), the licensee did not comply with the section cited above in 1 out of 2 staff did not have an updated Mandated Reporter Training certification of file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/16/2022
	Plan of Correction
1 2 3 4	Director Agrees to email Mandated Reporter Training Cercificate for Alicia Villa to LPA by 9/16/22.

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: 09/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2022

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 09/06/2022 03:47 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: IMMACULATE HEART OF MARY (PRESCHOOL)	FACILITY NUMBER: 414002663
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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
1 2 3 4	Based on (record review), the licensee did not comply with the section cited above in 1 out of 2 staff members did not have a Health Screening of file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/27/2022
	Plan of Correction
1 2 3 4	Director agrees to collect LIC 503 Health Screening for Alicia Villa and email to LPA by 9/27/22.

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
1 2 3 4	Based on (record review), the licensee did not comply with the section cited above in 1 out of 2 staff members did not have TB Clearance on file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/27/2022
	Plan of Correction
1 2 3 4	Director agrees to collect TB Clearance from staff Alicia Villa and email to LPA by 9/27/22.

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: 09/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2022

LIC809 (FAS) - (06/04)

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