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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700580
Report Date: 08/05/2022
Date Signed: 08/05/2022 12:51:39 PM

Document Has Been Signed on 08/05/2022 12:51 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:HUSD - BURBANKFACILITY NUMBER:
015700580
ADMINISTRATOR:RUBIO, ANN KRISTINNEFACILITY TYPE:
850
ADDRESS:222 BURBANK STREETTELEPHONE:
(510) 723-3805
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 0DATE:
08/05/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Kristina AdamsTIME COMPLETED:
01:00 PM
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A Prelicensing Visit was conducted today 08/05/2022 by Licensing Program Analysts (LPA) Melanie Otsuji. LPA met with Director of Early Learning, Kristina Adams. The applicant has submitted an application for a NEW for a PRESCHOOL license. Program is located on the campus of Burbank Elementary School in Room 7. The program will operate from 8:00AM - 4:00PM in one classroom with an AM/PM session. This is a TITLE V facility. A health and safety inspection was conducted inside and outside and the measurements are as follows:

INDOORS: 1098.72 square feet = 31 children
OUTDOORS: 21507.43 square feet = 286 children

The preschool room is equipped with varied age appropriate materials and equipment. There are 2 toilets and 2 sinks available for children use. There is an isolation tent set up on campus for ill children and children will utilize the nurses office toilet if needed. There is a food prep area. There is 1 play yard. Kinder playground is fenced in all around. Building overhang provide sufficient shade in the play yard The center has functioning drinking fountains inside, jugs and cups, as well as water bottles for indoor and outdoor activities. Hayward Unified School District will provide breakfast to AM class and lunch to PM class. No cleaning agents were found stored with food. First aid supplies are available in the center. There is a working telephone on site. Carbon monoxide is available.

A fire clearance from Hayward Fire Department was approved on 8/3/2022 for a capacity of 24 preschool aged children.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Melanie Otsuji
LICENSING EVALUATOR SIGNATURE: DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2022
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: HUSD - BURBANK
FACILITY NUMBER: 015700580
VISIT DATE: 08/05/2022
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This facility plans to provide Incidental Medical Services – IMS. For IMS information, see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. A Plan of Operation that includes IMS must be submitted to the Department. 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.

Ann-Kristinne Rubio is a fully-qualified preschool director and has completed 16 hours of health and safety training including pediatric CPR and First Aid.

LPA discussed the safe sleep regulations with Applicants 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 Applicants 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.

LPA reviewed with Applicants the LIC 311A, Records To Be Maintained At The Facility, for child’s records, personnel records, administrative records, and documents to be posted. Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

A license for 24 preschoolers operating out of 1 classroom will be approved once the following is received:


- Photographic proof of broken planter boxes in play yard be either repaired or removed.

An exit interview was conducted with Director of Early Learning, Kristina Adams.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Melanie Otsuji
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2022
LIC809 (FAS) - (06/04)
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