214005552-8-9-2021-05-CC-HRCO-C5QPDZ-20210809111422

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 214005552
Report Date: 08/04/2021
Date Signed: 08/09/2021 11:16:11 AM

Document Has Been Signed on 08/09/2021 11:16 AM - 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	SUSD- TOMALES PRESCHOOL		FACILITY NUMBER:	214005552
ADMINISTRATOR:	CUMMINGS, DAPHNE		FACILITY TYPE:	850
ADDRESS:	40 JOHN STREET		TELEPHONE:	(707) 878-2214
CITY:	TOMALES	STATE: CA	ZIP CODE:	94971
CAPACITY: 24	TOTAL ENROLLED CHILDREN: 0	CENSUS: 0	DATE:	08/04/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Daphne Cummings		TIME COMPLETED:	12:00 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	Licensing Program Analyst (LPA) Haydee Caliboso met with Daphne Cummings, Director of the facility on 8/4/21 for a pre-licensing inspection. The applicant has requested for a change of ownership and for a capacity of 24 children, ages two to Kindergarten. The facility will operate Monday - Friday; 8:00AM – 5:00PM. The facility is located on a functioning elementary school site of Shoreline Unified School District (SUSD) Tomales Preschool. The facility was inspected today, indoor and outdoor, for health and safety hazards, and measured to calculate capacity. Indoor: There is one classroom that will be used for the program and the following square footage was calculated for 886.065 sq. ft, allowing for a capacity of 24 children. The classroom’s furniture’s and equipment are clean and in good condition. Children’s toys and supplies are orderly, in good condition, and age appropriate. There is storage space for children's personal belongings located in the classroom. Mats will be utilized for napping children. Parents will provide a sheet and blanket for their child. Bedding is sent home to be washed weekly or as needed. Mats will be cleaned daily or as needed. The classroom is equipped with a fire extinguisher, smoke, and carbon monoxide detectors. The classroom is equipped with a working refrigerator. The classroom has garbage cans with tight-fitting lids. The classroom has a designated backpack with a first aid kit and emergency supplies. There is also a first aid kit located in the classroom. Refrigerated medications will be stored separately from food. Medication will be administered with parental consent and will be kept in the child’s file for record. All medication will be logged when administered to children. The program will program lunch and snacks daily for children. Cont. 809 pg.2

SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Haydee R Caliboso
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021

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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SUSD- TOMALES PRESCHOOL	FACILITY NUMBER: 214005552
	VISIT DATE: 08/04/2021

NARRATIVE

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The classroom has 2 sinks and 1 toilet available for children to use. The capacity for 1 toilet is 15, and the capacity for 2 sinks are 30. The applicant will submit a waiver request to use SUSD Tomales Elementary school restroom for shared restroom with preschool children. The applicant will make sure a postage sign is posted and available when preschool children are present. LPA reminded the Director that ratio and supervision are observed at all times. All cleaning supplies and hazardous items are stored in a locked cabinet made inaccessible to children. Isolation area for ill children is in the Director’s office, and staff bathrooms will be used for ill children. There are designated bathrooms for staff to use. Children will bring their own water bottle for indoor and outdoor use. In addition, pitchers of water and disposable cups will be provided for indoor and outdoor use.

Outdoor: The playground area that will be used in the program is shared with school-aged children in the facility. The playground area is separated into two playgrounds by a fence at least 4ft. tall. The outdoor square footage where children will be present during outdoor time is 9,956 sq.ft, allowing for a capacity of 24 preschool-age children. The facility will provide a request waiver for scheduled rotation for outdoor usage. The outdoor area was observed to be clean, safe, and equipped with toys that are age-appropriate for children. There is a tree in the playground that will be used for natural shade for children. The playground has swings and bike path. Wood chips are used on the playground for cushion. Sheds for storage will remain closed and locked when children are present. LPA reminded the Director Daphne Cummings to ensure ratio and supervision are observed at all times. The facility will conduct and log fire drills once every six months, and the log will be available upon request.

The following items were reviewed as part of today’s visit: Record keeping for staff, children, and facility records, care and supervision of the children, child discipline procedures – staff will use positive reinforcement and redirection.
Cont. 809 pg. 3

SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Haydee R Caliboso
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021

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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SUSD- TOMALES PRESCHOOL	FACILITY NUMBER: 214005552
	VISIT DATE: 08/04/2021

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Emergency Evacuation Procedures, Medication Policies, Isolation of Sick Children, Napping Requirements, Food Service, Transportation-none provided, Parents Rights, and Reporting Requirements.

This facility will provide Incidental Medical Services – IMS. LPA reviewed storage area for medication and equipment/supplies, and reviewed forms that will be used. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 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

An electronic copy of the three-page report was emailed to Daphne Cummings. Applicant were asked to review the report and return a signed copy of the report to LPA Haydee Caliboso.

Based on available square footage, sinks, and toilets, LPA Haydee Caliboso will recommend licensure of this facility for a maximum capacity of 24 children.

The following is required prior to regular licensure for a capacity of 24 children:
· Current Posting Requirements are posted
· Obtain approval from Marin County Fire Department
· A letter to request for shared usage of restroom with SUSD Elementary School.
· A letter to request for shared usage of outdoor scheduled rotation with SUSD Elementary School.

SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Haydee R Caliboso
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021

LIC809 (FAS) - (06/04)

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