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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415330
Report Date: 07/24/2019
Date Signed: 07/24/2019 11:58:52 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:STOCK FARM ROAD CHILDREN'S CENTERFACILITY NUMBER:
434415330
ADMINISTRATOR:J. FAJARDO & D. HOGUEFACILITY TYPE:
830
ADDRESS:183 STOCK FARM ROADTELEPHONE:
(650) 736-8465
CITY:STANFORDSTATE: CAZIP CODE:
94305
CAPACITY:48CENSUS: 13DATE:
07/24/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Debbie Hogue and Christine HerndonTIME COMPLETED:
12:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Case Management-Incident. LPA met with Director Debbie Hogue and Program Director Christine Herndon and explained the purpose of the inspection. The purpose of the investigation was to review a self-reported incident that involved C-1 receiving the wrong bottle on 06/25/2019. C-1 does have food allergies. C-1's parent was notified about the incident immediately.

LPA inspected the physical plant and inspected refrigerator for infant bottles and food. LPA observed that all foods and bottles are labeled with the child's name, current date, and the content of the bottle. LPA also reviewed child's file and staff training notes. LPA conducted staff and third party interview.

LPA discussed with Program Director and Director about incident in further detail and the corrective action that had been taken place following this incident. Program Director also conducted her own investigation in regards to the incident and informed LPA that S-1 was terminated. Program Director stated that she conducted training with all staff following the incident in regards to bottle feeding.

As a result of this investigation, a Type B citation has been cited. An exit interview where this report, citation, plan of correction, and appeal rights, were discussed and provided to Program Director. A Notice of Site Visit has been issued and must be posted for 30 consecutive days.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2019
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: STOCK FARM ROAD CHILDREN'S CENTER
FACILITY NUMBER: 434415330
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/31/2019
Section Cited
CCR
101223(a)(2)
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Personal Rights. The licensee shall ensure that each child is accorded the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
This requirement is not met as evident by:
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Deficiency cleared during inspection.

Program Director conducted a follow-up traning with all staff about bottle feeding procedures.
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Based on interview and record review, C-1 was given the wrong bottle on 06/25/2019 and does have food allergies. This poses a potential risk to the health and safety to the children in care.
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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: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2019
LIC809 (FAS) - (06/04)
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