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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004526
Report Date: 02/23/2024
Date Signed: 02/23/2024 12:35:22 PM


Document Has Been Signed on 02/23/2024 12:35 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:SAFARI KID MENLO PARKFACILITY NUMBER:
414004526
ADMINISTRATOR:MENON, SANDHYAFACILITY TYPE:
850
ADDRESS:107 CLOVER LANETELEPHONE:
(650) 322-0192
CITY:MENLO PARKSTATE: CAZIP CODE:
94025
CAPACITY:24CENSUS: 13DATE:
02/23/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Sandhya MenonTIME COMPLETED:
12:45 PM
NARRATIVE
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On February 23, 2024 Licensing Program Analyst (LPA) Kassandra Medrano conducted an inspection today due to a complaint that was submitted to San Bruno Regional office which was substantiated on 2/23/2024. During the inspection it was found that S3 was left alone with children in facility with expired CPR. It was found that S3's CPR expired on 5/23/2023.

California Code of Regulations, Title 22 deficiencies are being cited on the following page(s):

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Director, Sandhya Menon
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Kassandra MedranoTELEPHONE: (650) 400-9920
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2024
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 02/23/2024 12:35 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: SAFARI KID MENLO PARK
FACILITY NUMBER: 414004526

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/01/2024
Section Cited
CCR
101216(f)

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101216 Personnel Requirements
(f) At least one staff member who is trained in pediatric cardiopulmonary resuscitation and pediatric first aid pursuant to Health and Safety Code Section 1596.866 shall be present when children are at the child care center...
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Licensee stated that she would send in proof of enrollment of the required training.
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This requirement was not met as evidenced by: Based on interviews and documents reviewed S3 was left alone at facility with expired CPR training. This poses a potential health and safety risk to children enrolled.
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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: 02/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2