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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004595
Report Date: 07/06/2022
Date Signed: 07/06/2022 05:30:22 PM


Document Has Been Signed on 07/06/2022 05:30 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:BUILDING KIDZ PACIFICAFACILITY NUMBER:
414004595
ADMINISTRATOR:ROSARIO, LIBERTYFACILITY TYPE:
830
ADDRESS:401 PALOMA AVENUETELEPHONE:
(650) 557-1256
CITY:PACIFICASTATE: CAZIP CODE:
94044
CAPACITY:15CENSUS: 13DATE:
07/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:16 PM
MET WITH:Liberty RosarioTIME COMPLETED:
04:10 PM
NARRATIVE
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On July 6, 2022 at 12:16 PM, Licensing Program Analyst (LPA) Cowan met with Site Director, Liberty Rosario, for an unannounced annual random inspection. Present today is director, 4 staff, and 13 infants. Staff to child ratio was met on this day. The center operates Monday - Friday 7:30am to 5:30pm.

LPA inspected the infant day care area for health and safety hazards today. The center is clean, orderly and in good repair. There are no pools, spas or other similar bodies of water on site. Per director, there are no firearms or weapons on site. Cleaning supplies and other potentially harmful items are stored inaccessible to the children. All furniture and equipment are clean and in good working condition. The center's furniture and equipment are age appropriate. There is a sufficient quantity of cribs, table/chairs and changing tables meet the capacity. Parents provide bedding for cribs and mats. Bedding is sent home daily for cleaning by parents while cribs and mates are wiped down and disinfected daily. Bottles and other items provided by the parents are labeled and stored appropriately. Food and formula are provided by parents. The center has a working carbon monoxide detector. LPA observed infants were supervised by staff in the classrooms and in the napping area. All solid waste storage containers have secure lids. The outdoor play area designated for the infants and toddlers was in good repair. All toys and equipment are in working condition. Per director, toys are cleaned nightly. Areas under slides and other high climbing equipment is adequately cushioned with rubber mats.
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: April CowanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2022
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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Document Has Been Signed on 07/06/2022 05:30 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: BUILDING KIDZ PACIFICA
FACILITY NUMBER: 414004595

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) 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. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (record review)], the licensee did not comply with the section cited above person did not have Measles vaccine which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2022
Plan of Correction
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Director agrees to email LPA Measles for Alejandria Landinez by 7/15/22.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (record review)], the licensee did not comply with the section cited above in 2 people did not have training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2022
Plan of Correction
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Director agrees to email LPA Licensing documents by 7/15/22.

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: April CowanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/06/2022 05:30 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: BUILDING KIDZ PACIFICA
FACILITY NUMBER: 414004595

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(f)
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 or offsite for center activities.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (record review)], the licensee did not comply with the section cited above in no one on site had CPR Training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2022
Plan of Correction
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Director agrees to email LPA Licensing documents by 7/15/22.
Type B
Section Cited
CCR
101216(g)(1)
Personnel Requirements
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (record review)], the licensee did not comply with the section cited above in 1 staff did not have Health Schreening which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2022
Plan of Correction
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Director agrees to email LPA Licensing documents by 7/15/22. (Jessica Gallegos)

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: April CowanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/06/2022 05:30 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: BUILDING KIDZ PACIFICA
FACILITY NUMBER: 414004595

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(l)(1)(B)
Personnel Requirements
(B) A copy of the signed LIC 9052 (11/94) shall be kept in the employee's personnel record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above in one staff did not have form which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2022
Plan of Correction
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Director agrees to email LPA Licensing documents by 7/15/22.
Type B
Section Cited
CCR
101220(a)
Child's Medical Assessments
(a) Prior to, or within 30 calendar days following the enrollment of a child, the licensee shall obtain a written medical assessment of the child. This medical assessment enables the licensee to assess whether the center can provide necessary health-related services to the child.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (record review)], the licensee did not comply with the section cited above in 1 child did not have Physicians Report which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2022
Plan of Correction
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Director agrees to email LPA Licensing documents by 7/15/22.

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: April CowanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2022
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: BUILDING KIDZ PACIFICA
FACILITY NUMBER: 414004595
VISIT DATE: 07/06/2022
NARRATIVE
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At 1:30 PM, Staff files were reviewed. LPA observed that staff did not have current Mandated Reporter Training, Health Screening, and TB Clearance, and Employee Rights. At 3:36 LPA observed that three staff did not have fingerprints associated to the facility. LPA also observed that no staff had First Aid Training. Type B citations are issued for these deficiencies

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

Director was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with director and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee [facility representative] of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

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

DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2022
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: BUILDING KIDZ PACIFICA
FACILITY NUMBER: 414004595
VISIT DATE: 07/06/2022
NARRATIVE
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Director is aware that all staff is required to complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com. LPA observed the completion certificates on file. LPA encourages the director to frequently visit our website at www.ccld.ca.gov for licensing regulations and new updates.

>See next page for deficiencies

Exit interview conducted and report was reviewed with the director Liberty Rosario.

This report must be available in the facility for public review. Notice of site visit was observed being posted. Director was advised any additional questions to call Office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website: www.cdss.ca.gov

The copy of this report is reviewed and will be emailed to director. A reply is required demonstrating receipt.

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

DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2022
LIC809 (FAS) - (06/04)
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