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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004132
Report Date: 10/09/2020
Date Signed: 10/09/2020 11:01:06 AM

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: 16DATE:
10/09/2020
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Director, Carol ThomsenTIME COMPLETED:
09:15 AM
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Licensing Program Analyst (LPA), Cindy Interiano conducted a Case Management inspection and met with Director, Carol Thomsen via a Tele-inspection. Purpose of the inspection was explained to Director. Facility is currently licensed for 24 Preschool age children, operates in one Large classroom and uses Playground #1. Facility has requested use of an additional classroom in the adjacent building: P13/P14. Facility has also requested use of Playground #2, an outdoor play area adjacent to the Large classroom.

Director lead LPA on a virtual inspection of the facility indoors and outdoors for Health and Safety hazards. P13/P14 is one large classroom, which can be divided into two rooms with a ‘ceiling to floor’ divider. P13/P14 classroom has age appropriate toys and equipment for children. P13/P14 is equipped with an industrial fire alarm, a smoke and carbon monoxide detector, and a fire extinguisher. P13/P14 is equipped with a restroom with 1 toilet and 1 sink and two separate kitchenettes. Restrooms are maintained clean, in good repair, and with adequate supplies.
Playground #2 is adjacent to Large Classroom, and under minor renovations. Playground #2 will be completely fenced (before children’s use) and will be maintained free of debris and dangerous conditions. Playground #2 will have age appropriate toys and equipment for children and will be in good repair.

Director states there has been an initial Fire inspection, however a follow up Fire inspection is required.

During the tele-inspection, LPA provided Technical Assistance for Covid-19 guidelines, including Social Distancing, proper use of PPE equipment, and cleaning / disinfecting / sanitizing of commonly used areas/items.

Prior to updating license to include the P13/P14 and Playground #2,
> Fire clearance must be received.
> Final review is required from the Department.

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

>This report will be emailed to facility. This report must be available in the facility for public review. Any additional questions to call Office, M-F, 8a-5p, 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: 10/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2020
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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