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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004132
Report Date: 12/17/2019
Date Signed: 12/17/2019 12:50:18 PM

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:ALL FIVE @ BELLE HAVEN (PS)FACILITY NUMBER:
414004132
ADMINISTRATOR:CAROL THOMSENFACILITY TYPE:
850
ADDRESS:415 IVY DRIVE, PTBL 15TELEPHONE:
(650) 387-8268
CITY:MENLO PARKSTATE: CAZIP CODE:
94025
CAPACITY:24CENSUS: 19DATE:
12/17/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Director, Carol ThomsenTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA), Cindy Interiano, conducted a Case Management inspection and met with Director, Carol Thomsen. Purpose of the inspection was explained. Present during the inspection was Director and 6 Staff supervising 19 PreK children.
During the inspection, LPA and Director discussed an incident which occurred on 12/11/19, involving Child#1 who suffered a second degree burn on the upper thigh area. Staff#1 had direct supervision of 6 PreK children during the cooking project. A pot of hot water sat on a ‘hot plate,’ which was placed on a child’s table. Staff#1 instructed children to not touch the pot and to follow specific instructions. Staff#1 would call each child individually to pour in a spoonful of pasta into the pot. When it was Child#1’s turn, Child#1 poured a spoonful of pasta in the hot water, however when pulling out the spoon from the pot, a spoonful of hot water was scooped out, splashing Child#1 on the upper thigh area. Staff#1 immediately administered first aid. Staff#2 took over the cooking project. Director and Assistant Director assisted in administering first aid. Director contacted Guardian#1, who arrived within a half hour and took Child#1 to the doctors. Child#1 was diagnosed with a second degree burn and was referred to the burn clinic. Director states she has been in direct contact with Guardian#1. Director states Guardian#1 states Child#1 will remain at home until burn has healed and will later be returning to the facility.
Director states cooking/science projects are part to the program’s curriculum. Director states the children are given specific instructions and when a child is not developmentally or academically ‘ready’ to participate in the project, then other alternative activities are set up. Director states there are always 4-6 staff supervising the children. Director states future projects will not involve hot liquids.

A follow up inspection may be conducted.

***No deficiencies were cited against the facility under CCR,Title 22, Div. 12, Ch. 1. ***

>This report and rights to comment and appeal were discussed with Director. This report must be available in the facility for public review. Notice of site inspection was posted.
Director was advised any additional questions to call Office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website: www.ccld.ca.gov
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2019
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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