434408916-5-18-2022-52-CC-JWIS-CEK2NB-20220518173228

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434408916
Report Date: 05/18/2022
Date Signed: 05/18/2022 05:32:47 PM

Document Has Been Signed on 05/18/2022 05:32 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:	HEADSUP! CHILD DEVELOPMENT CENTER		FACILITY NUMBER:	434408916
ADMINISTRATOR:	KOSTEPEN, KIMBERLY		FACILITY TYPE:	830
ADDRESS:	2800 WEST BAYSHORE ROAD		TELEPHONE:	(650) 424-1221
CITY:	PALO ALTO	STATE: CA	ZIP CODE:	94303
CAPACITY:	24	CENSUS: 10	DATE:	05/18/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Kimberly Kostepen		TIME COMPLETED:	05:40 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 5/18/2022 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, Kimberly Kostepen. Present for this inspection was the Director, 4 fingerprint cleared and associated staff members, and 10 infants in care. Facility operating hours are 8am-6pm M-F. The facility was toured to conduct a health and safety inspection. At 9:30am, LPA toured the facility classroom. The facility consists of one classroom licensed for use by infants (classroom 1). The classroom 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. LPA observed adequate amounts of paper towels and hand soap available to children in the bathroom during today's inspection. Food/beverages capable of rapid spoiling are properly stored. Bottles, dishes and containers of food brought by the infants’ authorized representatives are labeled with infant’s name. The infant changing tables are placed within arm’s reach of a sink while in use. The facility shares a campus with a preschool component (434408915). The facility has indoor space for infants that is physically separate from space used by the preschool component.

SUPERVISOR'S NAME: Wynn Norona	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Jonathan Williams	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022

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 05/18/2022 05:32 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: HEADSUP! CHILD DEVELOPMENT CENTER	FACILITY NUMBER: 434408916
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101239(r)

Fixtures, Furniture, Equipment and Supplies

(r) Fixtures, furniture, and equipment that have been banned or recalled by the United States Consumer Product Safety Commission shall not be used or on the facility’s premises. 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 an infant bouncer and inclined sleeper present in the infant classroom during today's visit. This posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/18/2022
	Plan of Correction
1 2 3 4	Director removed the items from the facility during today's visit (5/18/2022).

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: Wynn Norona	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Jonathan Williams	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022

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: HEADSUP! CHILD DEVELOPMENT CENTER	FACILITY NUMBER: 434408916
	VISIT DATE: 05/18/2022

NARRATIVE

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At 3:56pm, LPA toured the outdoor play areas. Cushioning material is present in sufficient quantities to absorb falls. Outdoor play area is fenced and has a shaded area. All play equipment was observed to be in operable condition during today's inspection. There are no pools, hot tubs, ponds, or any other bodies of water accessible to children during today's inspection. Uncontaminated drinking water is present in the outdoor play areas for children to drink upon request.

At 4:20pm, LPA reviewed sign in/sign out sheet. LPA observed 10 signatures out of 10 children present today.

The facility has multiple fully-charged 3A400BC fire extinguishers and working telephone. Carbon monoxide detector is fully functional. Smoke detector/alarm is configured to alert the fire department when triggered, and Director stated the system is serviced regularly. At least one staff member present today has current CPR/1st Aid certificate. 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. Daily activity schedule is present in facility. Fire/disaster drill is conducted at least once every 6 months. Facility roster was obtained.

Incidental Medical Services (IMS) policy was discussed. This facility does not provide IMS to children in care at this time. 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.

SUPERVISOR'S NAME: Wynn Norona	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Jonathan Williams	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022

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: HEADSUP! CHILD DEVELOPMENT CENTER	FACILITY NUMBER: 434408916
	VISIT DATE: 05/18/2022

NARRATIVE

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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.

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 Director 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.

One deficiency was cited today. 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: 05/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022

LIC809 (FAS) - (06/04)

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