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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414002676
Report Date: 01/16/2020
Date Signed: 01/16/2020 03:31:18 PM

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:PENINSULA JEWISH COMMUNITY CENTER (SA)FACILITY NUMBER:
414002676
ADMINISTRATOR:SHIFRIN, NICOLEFACILITY TYPE:
840
ADDRESS:800 FOSTER CITY BLVDTELEPHONE:
(650) 378-2762
CITY:FOSTER CITYSTATE: CAZIP CODE:
94404
CAPACITY:120CENSUS: 19DATE:
01/16/2020
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Treehouse Manager, Jackelyn LathamTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Kassandra Medrano conducted an annual comprehensive inspection. Analyst toured the facility building and grounds, conducted an evaluation of the physical plant, and reviewed children, staff and facility records. A review of staff records during today’s visit indicates that all staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Days and hours of operation are: 12:45 PM- 6 PM, Monday- Friday.
The following items were reviewed as part of today's visit: Care and Supervision of the Children, Child Discipline Procedures, Emergency Evacuation Procedures (smoke and carbon monoxide detectors present and in working order), Medication Policies, Isolation of Sick Children, Napping Requirements, Food Service, Transportation, Parents Rights, and Reporting Requirements. Posting requirements for site visits were also discussed. Current forms and Title 22 Regulations can be obtained through the internet at www.ccld.ca.gov. Staff immunization are on file. Director was reminded 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. Influenza Declarations were also reviewed. Director was advised of Pesticides training. For More information about changes to the Healthy Schools Act, templates, articles, and required training you can inspect the DPR website at: https://apps.cdpr.ca.gov/schoolipm/childcare/training/main.cfm. Director was informed about the Provider Information Notices (PINs) on CCLD website. Director was reminded of Mandated Reporter Training available on CCLD website. Training must be renewed every two years.
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Kassandra MedranoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2020
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: PENINSULA JEWISH COMMUNITY CENTER (SA)
FACILITY NUMBER: 414002676
VISIT DATE: 01/16/2020
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The following items need to be completed and returned to Licensing by 02/16/2020:
-EMERGENCY DISASTER PLAN (LIC 610)
-NEW DIRECTOR INFORMATION: DESIGNATION OF ADMIN RESP (LIC 308), PERSONNEL RECORD (LIC 501), HEALTH SCREENING REPORT (LIC 503), IMMUNIZATION RECORD FOR MEASLES, PERTUSSIS AND INFLUENZA DECLARATION, LETTERS OF EXPERIENCE FROM PREVIOUS EMPLOYERS, TRANSCRIPTS/DEGREE/VALID CHILD DEVELOPMENT PERMIT, SIGNED STATEMENT ACKNOWLEDGING REQUIREMENT TO REPORT SUSPECTED CHILD ABUSE, SIGNED NOTICE OF EMPLOYEE RIGHTS AND CRIMINAL RECORD STATEMENT, PROOF OF COMPLETION OF 16 HOURS PREVENTATIVE HEALTH PRACTICES, INCLUDING CPR AND FIRST AID.



"NOTICE OF SITE VISIT" DOCUMENT WAS POSTED ADJACENT TO THE MAIN ENTRY DOORWAY AND VISIBLE TO PARENTS.
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Kassandra MedranoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2020
LIC809 (FAS) - (06/04)
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