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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414003031
Report Date: 04/28/2025
Date Signed: 04/28/2025 01:55:47 PM

Document Has Been Signed on 04/28/2025 01:55 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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:IHSD, INC-LAKEWOOD CDC (PS)FACILITY NUMBER:
414003031
ADMINISTRATOR/
DIRECTOR:		GHEITH, KIFAHFACILITY TYPE:
850
ADDRESS:65 TOWER ROADTELEPHONE:
(650) 578-3440
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY: 48TOTAL ENROLLED CHILDREN: 48CENSUS: 29DATE:
04/28/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:John FernandezTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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On 4/28/2025 at 8:40AM., Licensing Program Analyst (LPA), Luis Gomez met with Director, John Fernandez. The purpose of today's visit was explained and was for an unannounced, annual random inspection. This facility is licensed to operate a preschool-age program. Present was Director and 7 staff supervising 29 children. Facility staff present have criminal record clearances on file. Children present had been signed in by Guardians. Program utilizes two classrooms and two outdoor play areas. Classrooms include: Room #5, (3- 5 year old) and Room #7 (3- 5 year old). The outdoor play areas including the: #1, Main Yard; #2, Secondary Yard. Days and hours of operation are Monday- Friday 8:00AM- 4:00PM. Per Director, program operates year-around. LPA inspected facility, indoors and outdoors, for health and safety hazards.

At 8:55AM., LPA observed the following: The classrooms were equipped with age-appropriate materials and playthings available for the children. LPA observed cabinets, tables, and chairs are scaled to the appropriate size. Classroom materials, puzzles and supplies inspected were good repair. Accessible children's furniture was free of sharp corners or splinters. The classrooms have labeled cubbies for children’s belongings.

At 9:25AM., Based on observation, LPA confirmed carpet and children's sofa in classroom #7 door way. children's Sofa was form moved during inspection. Advisory Note: Technical Violation (LIC9102TV) was issued.

LPA reminder to ensure dirt and debris is removed from carpets regularly. Advisory Note: Technical Violation (LIC9102TV) was issued.

Children’s bathroom (shared between classrooms) was inspected. Bathroom was clean with adequate supplies for handwashing. LPA reminded director, children’s tooth brushes should be properly stored in clean drying rack. Facility has diaper changing tables for staff as needed.

For scheduled rest/ nap services, LPA observed stackable cots stored in facility. Per director, napping supplies are washed weekly. Facility had ventilation; adequate lighting; and was a comfortable temperature. Facility had a functioning telephone service; fire extinguishers (2A10BC); and carbon monoxide detector (Built-in). (REFER TO 809C, FOR CONT.)

Marie RodriguezTELEPHONE: (650) 266-8800
Luis GomezTELEPHONE: (650) 266-8800
DATE: 04/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 04/28/2025 01:55 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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: IHSD, INC-LAKEWOOD CDC (PS)
FACILITY NUMBER: 414003031

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
101238.2(d)(1)
Outdoor Activity Space
(d) The surface of the outdoor activity space shall be maintained: (1) In a safe condition for the activities planned.

This requirement is not met as evidenced by:
Deficient Practice Statement
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At 9:50AM., Based on observation, LPA confirmed several dividing gates without proper anchoring in the Secondary Play Area. This pose a potential health and safety risk to children in care.
POC Due Date: 05/09/2025
Plan of Correction
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Director will remove or anchor dividing gates in secondary play area by the due date: 5/9/2025.
Proof of correction will be submitted to the Department via email.
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.
Marie RodriguezTELEPHONE: (650) 266-8800
Luis GomezTELEPHONE: (650) 266-8800

DATE: 04/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2025

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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: IHSD, INC-LAKEWOOD CDC (PS)
FACILITY NUMBER: 414003031
VISIT DATE: 04/28/2025
NARRATIVE
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(Page 2)
Classrooms have their own, refrigerator/ food storage area. Areas inspected were free of liter/ rubbish. All food items reviewed had a current date and had been correctly stored.

At 9:45AM, LPA reviewed the outside play areas #1, #2. Outside play areas were completely enclosed. LPA observed absorbent rubber, installed underneath and around the climbing structure. LPA observed available shaded seating area for children. Sandbox was made inaccessible and is covered.

At 9:50AM., Based on observation, LPA confirmed several dividing gates without proper anchoring in secondary play area.

Per Director, water services are provided using refillable cups. Children’s water cups and large pitches are taken to the outdoor space for children to drink as they wish.

At 10:50AM., LPA reviewed facility records including a sample of the children files and personnel files. The personnel files reviewed contained: Teacher's Proof of Qualifications; Acknowledgement to Report Suspected Child Abuse (LIC9108); Immunization Record; Notice of Employee Rights form (LIC9052); and Personnel Record.

LPA reminded director ensure staff renew required mandated reporter training course (AB1207). Advisory Note: Technical Violation (LIC9102TV) was issued.

A sample of three children’s files were reviewed and contained the: Identification and Emergency Information (LIC700); Notification of Parent’s Rights (LIC995); Consent for Emergency Medical Treatment (LIC627); Immunization Record; and Personal Rights (LIC613A).

Staff's Cardiopulmonary Resuscitation / First Aid certification was current, expiring on: 3/25/2026.

Facility is conducting emergency disaster drills (Fire and Earthquake) every six months. Last drill was completed on 4/25/2025, and is logged.

Required postings are visible location with each classroom having their own set of forms. Forms include Facility License; Notification of Parent’s Rights (PUB394); Personal Rights (LIC613A); The Passenger Safety Laws (PUB269); Food Service (Menu) and Emergency Disaster Plan (LIC610). (REFER TO 809C, FOR CONT.)

SUPERVISOR'S NAME: Marie RodriguezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2025
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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: IHSD, INC-LAKEWOOD CDC (PS)
FACILITY NUMBER: 414003031
VISIT DATE: 04/28/2025
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Assembly Bill (AB) 2370, chapter 676, statues 2018 requires all licensed childcare centers (CCC’s) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and every five years after the date of the first test. LPA has verified that lead testing procedure was completed in accordance with the Written Directives outlined in PIN 21-21- CCP.

Director was reminded all adults 18 and over responsible for administration or direct supervision of staff, persons who provides care and supervision to children, and staff who have contact with children, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.

LPA and Director discussed Incidental Medical Services (IMS) policy. For IMS information see PIN 22-02CCP. 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) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website athttps://www.cdss.ca.gov/inforesources/community-carelicensing/subscribe and select the Child Care option to receive email communication.

Based on today's inspection, deficiencies were observed in the areas evaluated according to the Title 22 Division 12 Chap. 1 Ca. Code of Regulations and cited on LIC809D. An exit interview discussing, plan for correction and facility evaluation report was conducted with Director, John Fernandez.

Staff's signature on this form acknowledges receipt of these documents.

This report must be made available in facility for public review. Notice of site visit was provided and must remain posted for 30 days. Director was advised, for any additional questions to contact the Regional Office, Monday-Friday, 8:00am-5:00pm at 650-266-8800 or 1-844-538-8766. Website: www.ccld.ca.gov

SUPERVISOR'S NAME: Marie RodriguezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2025
LIC809 (FAS) - (06/04)
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