430700265-5-20-2022-52-CC-JWIS-CELTDQ-20220520143845

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 430700265
Report Date: 05/20/2022
Date Signed: 05/20/2022 02:38:58 PM

Document Has Been Signed on 05/20/2022 02:38 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME:	GRACE LUTHERAN PRESCHOOL		FACILITY NUMBER:	430700265
ADMINISTRATOR:	MCDERMOTT, PENNY		FACILITY TYPE:	850
ADDRESS:	3149 WAVERLY STREET		TELEPHONE:	(650) 493-8942
CITY:	PALO ALTO	STATE: CA	ZIP CODE:	94306
CAPACITY:	24	CENSUS: 8	DATE:	05/20/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:05 AM
MET WITH:	Penny McDermott		TIME COMPLETED:	02:52 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 5/20/2022, Licensing Program Analyst (LPA) Jonathan Williams arrived at the facility unannounced for the purposes of conducting a Required 1-Year Inspection. LPA was met by Director, Penny McDermott. Present for this inspection were the Director, one fingerprint cleared and associated staff member, one student volunteer from Foothill College, and 8 preschool aged children in care. Facility operating hours are 9am-1pm MWF and 9am-12pm T/Th. The facility was toured to conduct a health and safety inspection. At 11:14am, LPA toured the facility interior. The facility consists of two classrooms, one of which is currently used for storage and is off-limits to children, and one outdoor play area. The classroom used for childcare is tidy and clean with heating and ventilation for safety and comfort. There are safe age-appropriate toys and learning materials available to children throughout the classroom. All hazardous materials and toxins including disinfectants and cleaning solutions were observed to be made inaccessible to children during today's inspection. Furniture accessible to children was observed to be age-appropriate, in operable condition, and free of loose, sharp, or pointed parts. LPA observed adequate amounts of paper towels and hand soap available to children in the bathroom during today's inspection. At 11:28am, LPA toured the outdoor activity space. The outdoor activity space is fenced and was observed to be in safe condition during this inspection. All play equipment is operable and age-appropriate. Areas around high climbing equipment have cushioning material to absorb falls. Uncontaminated drinking water is available to children in the outdoor play area. Two chickens are kept in the outdoor activity space. Facility maintains an Animal Control Permit issued by the Palo Alto Police Department, Animal Control Unit. Permit expires on 02/2023.

SUPERVISOR'S NAME: Wynn Norona	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Jonathan Williams	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

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 05/20/2022 02:38 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: GRACE LUTHERAN PRESCHOOL	FACILITY NUMBER: 430700265
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101238(a)

Buildings and Grounds

(a) The child care center shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above. LPA observed chicken feces on the ground of the outdoor play area, posing a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/27/2022
	Plan of Correction
1 2 3 4	Director shall submit written plan to LPA detailing how chicken feces will be appropriately cleaned from areas accessible to children.

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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. LPA observed that the Direcor did not posess a current Mandated Reporter certificate, posing a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/27/2022
	Plan of Correction
1 2 3 4	Director shall submit proof of completion of training to LPA by the due date.

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: Wynn Norona	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Jonathan Williams	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: GRACE LUTHERAN PRESCHOOL	FACILITY NUMBER: 430700265
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101216(g)(2)

Personnel Requirements

(2) Each person specified in (g) above shall have a health-screening report signed by the person performing the screening. This report shall indicate the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. LPA observed that a staff member present today did not posess a signed health screening report containing TB clearance, posing a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/27/2022
	Plan of Correction
1 2 3 4	Director shall obtain report and submit to LPA by the due date.

Type B

Section Cited

CCR

101220.1(g)

Immunizations

(g) The licensee shall document each child's immunizations and shall maintain such documentation in the center for as long as the child is enrolled. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. LPA observed that immunization records for child in care C1 were missing from their file, posing a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/27/2022
	Plan of Correction
1 2 3 4	Director shall obtain records and submit to LPA.

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: Wynn Norona	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Jonathan Williams	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/20/2022 02:38 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: GRACE LUTHERAN PRESCHOOL	FACILITY NUMBER: 430700265
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101221(b)(5)

Child's Records

(b) Each record shall contain information including, but not limited to, the following: (5) Name, address and telephone number of the child's authorized representative and of relatives or others who can assume responsibility for the child if the authorized representative cannot be reached when necessary. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. LPA observed that Identification and Emergency Information Card, or its equivalent, was not present for child in care C5. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/27/2022
	Plan of Correction
1 2 3 4	Director shall obtain document and submit to LPA.

Type B

Section Cited

CCR

101221(b)(8)(C)

Child's Records

(C) A signed consent form for emergency medical treatment unless the child's authorized representative has signed the statement specified in Section 101220(f). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. LPA observed that consent forms for emergency medical treatment for chidlren in care C1, C3, C5, and C8 lacked parent signatures. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/27/2022
	Plan of Correction
1 2 3 4	Director shall obtain signatures and submit to LPA.

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: Wynn Norona	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Jonathan Williams	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: GRACE LUTHERAN PRESCHOOL	FACILITY NUMBER: 430700265
	VISIT DATE: 05/20/2022

NARRATIVE

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Director stated to LPA that food is prepared by parents and is sent to the center with their children. At this time, the facility only provides occasional snack food to children. Food is properly stored and Director stated that contaminated food is discarded immediately. Refrigerator was observed to be maintained in working order and was found to be free of evidence of rodents and other vermin at this time.

The facility has one fully charged 2A10BC fire extinguisher and working telephone. Carbon monoxide/smoke detector (combined) is functional. The facility is in ratio today. Children's files and staff files were reviewed for proper documentation. All required forms are posted in public view. Facility roster was obtained. LPA reviewed sign in/sign out sheet and LPA observed 8 signatures out of 8 children present in the facility during today's inspection.

Incidental Medical Services (IMS) policy was discussed. This facility does not provide IMS to children in care. 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. Director is additionally reminded that student volunteers must be directly supervised by the licensee or a facility employee with a criminal record clearance or exemption and that student volunteers may not spend more than 16 hours per week at the facility.

Director was reminded that California Law requires licensed Child Care Centers to report unusual incidents or injuries to children in care to child's parents and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone, fax, or electronic mail. LPA informed the Director that all forms can be downloaded at www.ccld.ca.gov and encouraged the Director to email childcareadvocatesprogram@dss.ca.gov to be included in the Child Care Quarterly Updates distribution list. The Director was also reminded that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.

SUPERVISOR'S NAME: Wynn Norona	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Jonathan Williams	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: GRACE LUTHERAN PRESCHOOL	FACILITY NUMBER: 430700265
	VISIT DATE: 05/20/2022

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	There are deficiencies cited. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Director. Appeal rights were provided to the Director and the signature on this form acknowledges receipt of these rights.

SUPERVISOR'S NAME: Wynn Norona	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Jonathan Williams	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

LIC809 (FAS) - (06/04)

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