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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430700018
Report Date: 05/09/2019
Date Signed: 05/09/2019 12:43:00 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:DOWNTOWN CHILDREN'S CTRFACILITY NUMBER:
430700018
ADMINISTRATOR:MOMAND, MELISSAFACILITY TYPE:
850
ADDRESS:555 WAVERLYTELEPHONE:
(650) 321-9578
CITY:PALO ALTOSTATE: CAZIP CODE:
94301
CAPACITY:24CENSUS: 22DATE:
05/09/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Melissa MomandTIME COMPLETED:
12:55 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Tuoc Doan and Monica Mathur conducted an unannounced Case Management visit to the Preschool to follow up with an incident involving Child 1. LPA met with Director Melissa Momand and explained the purpose of the visit.

Facility reported to Community Care Licensing Office the following:
On Tuesday, 04/23/19, Child 1 sustained an injury while playing outside on the play structure.

LPAs interviewed staff to obtain further information regarding this incident. Records were reviewed and copies were obtained.

Based on information obtained from interviews and records reviewed, a regulatory violation was found. Therefore, a citation was issued during the site inspection.

Exit Interview was conducted, where this report, the citation, and plan of corrections were reviewed and discussed with Director Melissa Momand.

LPAs also reviewed with Director the facility’s rights to appeal the citation should the facility disagrees. LPAs provided a copy of this report and the appeal procedure to the facility at the conclusion of the visit.

A NOTICE OF SITE VISIT WAS ISSUED AND MUST BE POSTED ON OR ADJACENT TO THE INTERIOR SIDE OF THE MAIN DOOR INTO THE FACILITY FOR 30 CONSECUTIVE DAYS.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 334-2151
LICENSING EVALUATOR NAME: Tuoc DoanTELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2019
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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: DOWNTOWN CHILDREN'S CTR
FACILITY NUMBER: 430700018
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/17/2019
Section Cited
CCR
102416.2(f)
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REPORTING REQUIREMENT. As soon as possible but no later than the same business day, the licensee shall notify a child's parent regardless of the injuries [...] as specified in Health and Safety Code Section 1597.467.
This requirement is not met as evidenced by: Based on interviews with staff and records
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BY POC DUE DATE, 05/17/19, Facility will conduct an In-Service Training for Staff to review their reporting procedure to ensure that parents are notified as soon as possible when an incident happened with their child. A copy of the training log will be sent to Licensing Office to show proof of attendance and topic
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reviewed, Child 1 cried after she fell on the play structure on 04/23/19. Child 1's parent was not notified of the incident until the following morning when the parent called the facility because the parent noticed bruising on the child. This poses a potential risk to the health and safety of chidlren in care.
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reviewed.
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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: Sandy KnightTELEPHONE: (408) 334-2151
LICENSING EVALUATOR NAME: Tuoc DoanTELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2019
LIC809 (FAS) - (06/04)
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