434400470-10-3-2022-52-CC-CURE-CJUL7E-20221003083012

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434400470
Report Date: 09/30/2022
Date Signed: 10/03/2022 08:30:35 AM

Document Has Been Signed on 10/03/2022 08:30 AM - 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:	LOS ALTOS UNITED METHODIST CHURCH CC.		FACILITY NUMBER:	434400470
ADMINISTRATOR:	HEIDI BLISS		FACILITY TYPE:	850
ADDRESS:	655 MAGDALENA AVENUE		TELEPHONE:	(650) 941-5411
CITY:	LOS ALTOS	STATE: CA	ZIP CODE:	94024
CAPACITY:	140	CENSUS: 64	DATE:	09/30/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:			TIME COMPLETED:	03:45 PM

NARRATIVE

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On 09/30/2022 at 9:30am, Licensing Program Analyst (LPA) Christina Uribe conducted an Unannounced Annual Required Inspection. LPA met with facility representative, Merry Cohn, also present at the time of the inspection were 13 staff & 64 children. The facility is within ratio & capacity compliance today. LPA provided facility representative the Entrance Checklist (LIC 125). The facility was toured to conduct a Health and Safety inspection. The facility currently operates 8:00am-3:30pm, Monday-Friday in six classrooms.

Classrooms: All classrooms were inspected for age-appropriate furnishings, equipment, & adequate storage for children’s belongings. LPA observed the cleanliness of floors & surfaces, the presence of a fully functional carbon monoxide detector, smoke detector/fire alarms, and a fully charged 3A40BC fire extinguisher that is accessible throughout the facility. The center is equipped with a fully stocked first-aid kit and available in the classrooms.

Food Service Areas: All center provided food items are properly labeled & stored separately from cleaning supplies. Food prep area is clean, adequately equipped, & free from hazardous materials. Snack menu must be posted one week in advance, available for review, & dated which it is not. All solid waste bins are equipped with a tight fitting lid.

Bathrooms: Facility has separate staff and child designated bathrooms. Toilets and faucets are in safe and sanitary operating condition. The children are able to reach the sinks and toilets. Supplies are available to children.

Outdoor Play Area: There are no bodies of water, or free-standing water accessible to children. There are age appropriate toys and materials for the children. The playground outside is fenced and all equipment and surfaces are free from hazards.

Page 1 of 3 ***Continued on LIC 809C***

SUPERVISOR'S NAME: Chandra Charles	TELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Christina Uribe	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022

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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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: LOS ALTOS UNITED METHODIST CHURCH CC.	FACILITY NUMBER: 434400470
	VISIT DATE: 09/30/2022

NARRATIVE

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Records: All individuals subject to criminal record review have a clearance and have been associated to the facility. LPA reviewed 10 children’s files and 10 staff files. LPA reviewed the facility roster & personnel record. At least one opening/closing staff member has a current Pediatric CPR/First-Aid Certification. Mandated Reporter certificates were reviewed. The center is not in compliance with sign in and out procedure as one child was not signed in by their authorized representative when dropped off for care today. Emergency Drills are recorded and performed at least every six months. Per facility representative, there are no firearms on the premises. All required documents are posted in a publicly accessible area.

Health-Related Services: This facility does provide Incidental Medical Services (IMS). LPA inspected storage of medications and equipment/supplies, and reviewed children’s, personnel, and administrative records. 4 children have an epinephrine pen at the facility but do not have a signed consent for medication administration form which results in a Type B violation being issued today. For IMS information see Evaluator Manual – Regulation Interpretations & Procedures for Child Care Centers sections 101173 & 101226. 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

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Facility representative 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.

Effective August 1, 2003 California Law requires Child Care Licensees 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 to the regional office by phone and the written report, LIC 624, within 7 business days.

Page 2 of 3 ***Continued on LIC 809C***

SUPERVISOR'S NAME: Chandra Charles	TELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Christina Uribe	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022

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: LOS ALTOS UNITED METHODIST CHURCH CC.	FACILITY NUMBER: 434400470
	VISIT DATE: 09/30/2022

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Please see attached deficiency and advisory note pages for citation and technical violations cited today:

Type B Violation: 4 children have medications at the facility which do not have a signed consent for medication administration form accompanying them.
Technical Violation: Medications kept at the facility do not have their original packaging/container with the prescription label.
Technical Violation: Medications are kept in a backpack and go in and out of the classroom with the class, however, the medications should be stored in a more secured manner.
Technical Violation: Snack menu must be created in a calendar format and available at least one week in advance for review.
Technical Violation: One child was not signed in this morning when dropped off to attend care for the day.
Technical Violation: Incomplete children's records. At least one child does not have proof of immunization nor a Physician's Report (LIC 701).

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Appeal Rights were given and reviewed. Exit interview conducted and report was reviewed with the facility representative, Merry Cohn.

Page 3 of 3 ***End of Report***

SUPERVISOR'S NAME: Chandra Charles	TELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Christina Uribe	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022

LIC809 (FAS) - (06/04)

Page: 3 of 9

Document Has Been Signed on 10/03/2022 08:30 AM - 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: LOS ALTOS UNITED METHODIST CHURCH CC.	FACILITY NUMBER: 434400470
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101226(e)(3)(B)

Health-Related Services

(3) Prescription medications may be administered if all of the following conditions are met: (B) For each prescription medication, the licensee shall obtain, in writing, approval and instructions from the child's authorized representative for the administration of the medication to the child. 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 as four children who have medication stored at the facility do not have a signed consent form for the administration of medication which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/28/2022
	Plan of Correction
1 2 3 4	Parents whose children have medication stored at the facility will sign the Parent Consent for Administration of Medication (LIC 9221) form. The director will email a scanned copy of these forms to LPA Uribe at christina.uribe@dss.ca.gov no later than the due date of 10/28/2022 in order to clear the deficiency.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Chandra Charles	TELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Christina Uribe	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022

LIC809 (FAS) - (06/04)

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