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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004132
Report Date: 05/18/2022
Date Signed: 05/18/2022 01:33:38 PM


Document Has Been Signed on 05/18/2022 01:33 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:ALL FIVE @ BELLE HAVEN (PS)FACILITY NUMBER:
414004132
ADMINISTRATOR:CAROL THOMSENFACILITY TYPE:
850
ADDRESS:415 IVY DRIVETELEPHONE:
(650) 387-8268
CITY:MENLO PARKSTATE: CAZIP CODE:
94025
CAPACITY:40CENSUS: 33DATE:
05/18/2022
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Carol ThomsenTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Marie Rodriguez made an announced Case Management inspection. LPA met with Director Carol Thomsen and explained purpose of inspection. Licensee is requesting an increase of capacity to 60 children and the room additions of P17 (East Room), P18 (Center Room), and P19 (West Room). Facility currently has a capacity of 40 children and uses rooms P15 and P16. Present at the facility were the Director, 6 teachers, and 33 children (preschool aged). Once additional rooms have been licensed, rooms P15 and P16 will no longer be in use and will be renovated. Facility was inspected today for health and safety hazards and measured to calculate capacity.

LPA and Director toured rooms P17, P18, and P19 for health and safety hazards. Each classroom is equipped with an industrial fire alarm, a smoke and carbon monoxide detector, and a fully charged fire extinguisher. Each classroom has a bathroom with two toilets and one sink. A second sink right outside of the bathroom will be used for children's use. Room P17 has appropriate chairs and tables for children along with cots on the side wall. There is a storage space for children's personal belongings. Children's toys, furniture, and other equipment for rooms P17, P18 and P19 will be moved from classrooms P15 and P16 once license has been approved since it's currently in use.

Indoor: Total useable indoor area for rooms P17, P18, and P19 measures at 2,547.52 sq ft divided by 35 sq ft equals 72 children. Outdoor: Total useable outdoor area measures at 10,960.52 sq ft divdied by 75 sq ft equals 146 children. Licensee is requesting an increase of capacity for a total of 60 children.

An initial fire clearance inspection was conducted on Thursday, April 28, 2022. Licensee was requested to move the position of the fire extinguisher in each classroom. Follow up inspection will be completed by fire inspector.

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SUPERVISOR'S NAME: Daniel J OquendoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Marie RodriguezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2022
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: ALL FIVE @ BELLE HAVEN (PS)
FACILITY NUMBER: 414004132
VISIT DATE: 05/18/2022
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LPA will approve the increase of capacity to 60 children and room additions of P17, P18, and P19 once fire clearance has been granted by Fire Inspector.

LPA also requests the following:
  • Pictures of rooms P16, P17, and P18 once they have been fully furnished.
  • Pictures of how the space next to the sink counter in each classroom has been utilized. (Plan is to install a table to be flush with the counter space.)
No deficiencies cited today under California Code of Regulations, Title 22, Division 12.

Report was reviewed and discussed with Director Carol Thomsen. A copy of report was provided.
SUPERVISOR'S NAME: Daniel J OquendoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Marie RodriguezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022
LIC809 (FAS) - (06/04)
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