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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414098
Report Date: 06/03/2022
Date Signed: 06/03/2022 02:32:28 PM


Document Has Been Signed on 06/03/2022 02:32 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:WALDORF SCHOOL OF THE PENINSULAFACILITY NUMBER:
434414098
ADMINISTRATOR:MEGAN LINFACILITY TYPE:
850
ADDRESS:11311 MORA DRIVETELEPHONE:
(650) 209-9400
CITY:LOS ALTOSSTATE: CAZIP CODE:
94024
CAPACITY:45CENSUS: 27DATE:
06/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Megan LinTIME COMPLETED:
03:00 PM
NARRATIVE
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On 06/03/2022 at 9:00am, Licensing Program Analyst (LPA) Christina Uribe conducted an Unannounced Annual Required Inspection. LPA met with Director, Megan Lin, also present at the time of the inspection were 5 staff & 27 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 8:10am-5:45pm, Monday-Friday in the Honey Bee, Apple Blossom, & Blue Bell 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 is posted one week in advance, available for review, & dated. 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 CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Christina UribeTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2022
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 06/03/2022 02:32 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: WALDORF SCHOOL OF THE PENINSULA
FACILITY NUMBER: 434414098

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101170(e)(1)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as one staff member does not have an eligible background clearance and is not associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2022
Plan of Correction
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Staff member was immediately excused from the premises and director is instructed that this individual cannot return until a fingerprint scan has been performed and a criminal background check has been processed and cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Christina UribeTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 06/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2022
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: WALDORF SCHOOL OF THE PENINSULA
FACILITY NUMBER: 434414098
VISIT DATE: 06/03/2022
NARRATIVE
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Records: All individuals subject to criminal record review have a clearance and have been associated to the facility, with the exception of one employee. This employee does not have an eligible background clearance and is not associated to the facility resulting in a Type A violation. LPA reviewed 10 children’s files and 6 staff files around 10:30am. 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. Director’s CPR/First-Aid Certificate is current and expires on 07/27/2023. The center is in compliance with sign in and out procedure. Emergency Drills are recorded and performed 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), however no children have the need for medication to be stored at the facility at this time. 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.

Licensee 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 CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Christina UribeTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2022
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: WALDORF SCHOOL OF THE PENINSULA
FACILITY NUMBER: 434414098
VISIT DATE: 06/03/2022
NARRATIVE
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Deficiencies Cited During Today's Inspection: Please see attached deficiency and advisory notes pages.
  • Type A Violation: One staff member does not have an eligible background clearance and is not associated to the facility. A civil penalty of $500.00 is being issued today. Please see LIC421BG form for additional information.
  • Technical Violation: One staff member needs to renew her Mandated Reporter Certification and another staff member only has certification for the General Training, not the Child Care Provider (AB 1207) training.
  • Technical Violation: Children's files are stored electronically. A complete and separate file for each child needs to be maintained and immediately available for review upon request by the Department.

LPA Uribe informed licensee that this report dated 06/03/2022 documents one Type A citation which shall be posted for 30 consecutive days as there is/are immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Uribe informed the licensee to provide a copy of this licensing report dated 06/03/2022 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

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. Exit interview conducted and report was reviewed with the director, Megan Lin.

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

SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Christina UribeTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2022
LIC809 (FAS) - (06/04)
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