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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434408056
Report Date: 05/24/2019
Date Signed: 05/24/2019 11:57:00 AM

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:STRATFORD SCHOOLFACILITY NUMBER:
434408056
ADMINISTRATOR:SMRITI DATTAFACILITY TYPE:
850
ADDRESS:870 NORTH CALIFORNIA AVENUETELEPHONE:
(650) 493-1151
CITY:PALO ALTOSTATE: CAZIP CODE:
94303
CAPACITY:216CENSUS: 157DATE:
05/24/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Smriti DattaTIME COMPLETED:
12:10 PM
NARRATIVE
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A visit was made to follow up on a self reported incident where the child got injured. Met Smriti, Site Director, purpose of visit explained. Her statement was taken, child's file reviewed, all staff who had contact with him in the afternoon were interviewed. One staff was interviewed via phone. Parent didn't not provide any medical documents to faciltiy Sign in sheet indicates he was picked up on 04/29/19 at 12 o'clock that day, Mom didn't sign him back in when she brought him back and staff think he came back around 2:45. Often parents pick him up at some point during the day and bring him back. The playground was inspected as well as the classroom.
Per information obtained during the course of the interviews, it is unknown what exactly caused the injury and when it happened as he was out of the center for couple of hours that day.
However looking at the sign in and out sheet and the print out of the electronic sign in and out he is not always signed in and out accurately.
Please see next page for citation under Title 22.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Mahvash BehboodTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2019
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: STRATFORD SCHOOL
FACILITY NUMBER: 434408056
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2019
Section Cited
CCR
101229.1(a)(c)
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Sign in and out - A person who removes the child from the center during the day, and returns the child to the center the same day, shall sign the child in/out. This particular child is often picked up by parent during the day and comes back. It was noted that the parent is not signing him in and out properly. This is potentially dangerous to health and safety of children.
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Facility to create a form that have culoms to allow parent to sign out and in during the day in addition to culom to sing in and out in the mooring and final pick up. A copy of form should be sent to analyst by due date. Also parents must be notify of the new form and procedure of sign in and out.
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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: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Mahvash BehboodTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2019
LIC809 (FAS) - (06/04)
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