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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004132
Report Date: 08/28/2024
Date Signed: 08/28/2024 03:50:50 PM


Document Has Been Signed on 08/28/2024 03:50 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: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:60CENSUS: 41DATE:
08/28/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Austreberta "Berta" Garcia LopezTIME COMPLETED:
04:00 PM
NARRATIVE
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On August 27, 2024 Licensing Program Analyst (LPA) Kassandra Medrano made an unannounced case management inspection and met with Facility Representatives, Jenna Wachtel Pronovost and Ana Guanzon. The purpose of the visit was explained, with facility representatives. LPA toured facility with Facility representatives, during this tour LPA observed 3 individuals in ratio that were not associated to the facility. During inspection of the classrooms, LPA observed cleaning products accessible to children. As well as children opening and closing drawers that had safety locks. Due to technical difficulties the report did not print during Inspection.

Today, 08/28/24 LPA returned to deliver report and review with facility representatives, Berta and Ana Guanzon. At this time the director, Carol Thomsen, is out on sabbatical and has appointed Austreberta "Berta" Garcia Lopez as designated facility representative in her absence.


FACILITY MUST POST ANY TYPE A DEFICIENCIES DURING TODAYS VISIT WITH THE NOTICE AND FACILITY UNDERSTANDS THE NOTICE AND TYPE A DEFICIENCIES MUST REMAIN POSTED FOR THIRTY DAYS. REQUIREMENTS FOR AB 633 FACT SHEET AND A COPY OF ACKNOWLEDGEMENT OF RECEIPT OF LICENSING REPORTS (LIC 9224) WERE DISCUSSED WITH FACILITY REPRESENTATIVE. FACILITY UNDERSTANDS THIS REQUIREMENT.

This TYPE A citation page shall be posted for 30 days along with the “Notice of Site Visit.” This page shall be provided to all parents of children currently enrolled, and any future children being enrolled for the next 12 months per AB 633 requirements.

California Code of Regulations, Title 22 deficiencies are being cited on the following page(s):
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Kassandra MedranoTELEPHONE: (650) 400-9920
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 08/28/2024 03:50 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: ALL FIVE @ BELLE HAVEN (PS)
FACILITY NUMBER: 414004132

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/28/2024
Section Cited
CCR
101170(e)(2)

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1010170(e)(2) Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:
(2) Request a transfer of a criminal record clearance as specified in Section 101170(f)
This requirement was not met as evidenced by:
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During inspection SBRO associated the 3 individuals to the preschool program.
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Based on record review it was found that 3/11 preschool staff were not associated to the preschool program. This poses an immediate health and safety risk to children in care.
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Type A
09/18/2024
Section Cited
CCR101283(g)

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101238(g) Building and Grounds(g) Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to children. This requirement was not met as evidenced by:
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During inspection LPA moved accessible matierials out of reach of children. Facility to send documentation of new locks installation
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Based on observations it was found in all three classrooms that cleaning products were accesible to children. As well as LPA observed child opening the safety locks put in place for the cabinets. This poses an immediate health and safety risk to children in care.
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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.
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Kassandra MedranoTELEPHONE: (650) 400-9920
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
LIC809 (FAS) - (06/04)
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