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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004479
Report Date: 09/21/2021
Date Signed: 09/21/2021 01:43:01 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:GOLDEN STATE PRESCHOOLFACILITY NUMBER:
414004479
ADMINISTRATOR:SU, SONIAFACILITY TYPE:
850
ADDRESS:374 CATHERINE DRIVETELEPHONE:
(415) 990-1354
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:48CENSUS: 21DATE:
09/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Xiaotian "Tara" YuTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Andrea Medlin met with co-director for this required annual licensing visit. Purpose of visit explained. Facility operates a preschool program. There are 21 children present during the visit. Days and hours of operation: Monday-Friday 8:30AM-6:00PM. The facility has fully charged fire extinguisher that meet the minimum requirements, smoke detectors, and carbon monoxide (CO) detectors in facility. Children's bathrooms inspected; all toilets and hand washing facilities are in safe and sanitary operating condition. No pools, spas, hot tubs, fish ponds, or similar bodies of water are present. Per director, there are no firearms or weapons on site. Disinfectants, cleaning solutions, poisons and other items that are dangerous to children are inaccessible. Variety of age appropriate toys and materials for children is available. Classrooms are set up for child care and furniture and equipment for children is present. Facility provides snacks and meals. Adequate first aid supplies are available. Sick children will be separated from the group while waiting for parents to pick up. Outdoor play area inspected for health and safety hazards. The areas used for outdoors is completely gated. Outdoor activity space surfaces are free of hazards. Facility has posted all the required licensing forms in a prominent accessible location: License, Parent's Rights (LIC 995), and Emergency Disaster Plan (LIC 610). LPA reviewed staff and children's files. LPA reviewed staff and children's files. In the children's files that were reviewed, each child had a complete record maintained. In the staff files reviewed, co-director needs verification of the mandated child abuse reporting training (AB1207) and S1 needs verification of the required immunizations: measels (MMR) and pertussis (Tdap).

The deficiencies cited on the following pages are in violation of the California Code of Regulations, Title 22, Division 12, Chapter 1:

This report is reviewed with co-director and a copy of this report must be made available for public review upon request.

Notice of site visit posted and shall remain posted for 30 days

SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Andrea MedlinTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
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
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: GOLDEN STATE PRESCHOOL
FACILITY NUMBER: 414004479
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/12/2021
Section Cited

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H&S Code 1596.8662(3) On and after January 1, 2018, a person who becomes an administrator or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs....
(continued below)
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(2) and (3) of subdivision (a) within the first 90 days of employment. This requirement is not met as evidenced by staff file reviews. Co-director (S2) does not have the mandated child abuse reporting training as compliant with AB 1207.

This is a potential health and safety risk.
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Send proof of correction to the licensing office by 10/12/2021.

Failure to correct by due date may result in a return licensing visit.
Type B
10/12/2021
Section Cited

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H&S Code 1596(a)(1) Employees or volunteers at day care center; immunization requirements: Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles.
(continued below)
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Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
This requirement is not met based on file reviews. S1 does not have verification of the required immunizations.

This is a potential health and safety risk.
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Send proof of correction to the licensing office by 10/12/2021.

Failure to correct by due date may result in a return licensing visit.
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: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Andrea MedlinTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2