214005669-12-19-2023-05-CC-CQUO-CYNRCY-20231219115507

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 214005669
Report Date: 12/19/2023
Date Signed: 12/19/2023 11:55:12 AM

Document Has Been Signed on 12/19/2023 11:55 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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	YMCA SF-MARIN HEARTWOOD CHARTER SCHOOL		FACILITY NUMBER:	214005669
ADMINISTRATOR:	KELLEY, TORREY		FACILITY TYPE:	840
ADDRESS:	3125 SIR FRANCIS DRAKE BLVD.		TELEPHONE:	(415) 897-3196
CITY:	FAIRFAX	STATE: CA	ZIP CODE:	94930
CAPACITY: 100	TOTAL ENROLLED CHILDREN: 0	CENSUS: 0	DATE:	12/19/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Jeanie Calagui		TIME COMPLETED:	12:10 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 December 19, 2023 at approximately 9:00am, Licensing Program Analyst (LPA) Catrina Quimbo, conducted a pre-licensing inspection. LPA met with director of youth development, Jeanie Calagui, and site coordinator, Ri Berkowitz, and explained the purpose of the inspection. The application was submitted to department December 1, 2023. Application is requesting a school age license for 100 children (kindergarten to 6th grade). The YMCA program will operate Monday through Thursday, with morning hours of 7:00am to 8:00am and afternoon hours of Mondays, 12:30pm to 6:00pm and Tuesdays through Thursdays 1:30pm to 6:00pm. The YMCA after school program will operate at Heartwood Charter School in the dining hall, kinder outdoor area, open space field located behind kinder area, and the Bush Unit (restrooms only). The designated director for site will be Jeanie Calagui. The site coordinator will be Ri Berkowitz. The facility was inspected, indoors and outdoors, for health and safety hazards. The school age program is exempt from requirements for indoor and outdoor square footage, fencing, and toilet/sink ratios. No measurements were taken during LPA's visit. LPA reminded director and site coordinator, department must inspect and approve of any new space that was not inspected during today's visit, prior to its use. Indoors: The main area for YMCA program will be in the dining hall. LPA observed the dining hall to be equipped with appropriate furniture and materials. YMCA program's materials are stored in the art barn and are stored daily and are brought to the dining hall. Dining hall is equipped with fire sprinklers and a fully charged fire extinguisher. Per director of youth development, there is a dual smoke/carbon monoxide detector that will be stored next to the fire extinguisher. YMCA program plans to utilize portable carts that will be transferred indoors and outdoors that will include fully stocked first aid kits and children's documentation. All toxins and hazardous items will be stored in art barn shed, inaccessible to children. Isolation for a sick child will be in the dining hall, separate from other children in care. YMCA program will have access to multiple bathrooms, 2 in dining hall and 3 in the bush unit. Restrooms allow for individual privacy. Director of youth development and site coordinator were reminded staff are to not utilize restrooms while children use restrooms. (Continue Report on Page 2...)

SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

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

FACILITY NAME: YMCA SF-MARIN HEARTWOOD CHARTER SCHOOL	FACILITY NUMBER: 214005669
	VISIT DATE: 12/19/2023

NARRATIVE

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Program will provide afternoon snacks only. There is a kitchen in the dining hall that will not be utilized by YMCA staff. Storage for food will be in the staff lounge in separate building, in the Little House. Director of youth development and site coordinator were reminded toxins and poisons cannot be stored next to food. Water is accessible to enrolled children with a refillable water station located in the dining hall.

Outdoors: There are two outdoor areas YMCA program will have access to: the kinder area and the open space area. Kinder area is fully fenced and enclosed. LPA observed kinder area to have sufficient toys and materials. There is a chicken coop in the kinder area that will be closed and made inaccessible to children during YMCA program hours. The open space area is located adjacent to the kinder area. Program plans to provide children's toys and materials daily that will be stored in art barn. LPA observed open space to be a field with surrounding trees. There is a creek located next to the open field, that is low. LPA discussed with director and site coordinator of management approval for open space area as outdoor area. Director and site coordinator were reminded children must always be supervised going to and from restroom, playground area and dining hall.

Site coordinator was reminded disaster drills are conducted at least once every six months and must be properly logged. Licensing documentation and posters were properly posted and made available for review in dining hall. Children will be signed in and out of program with authorized representatives' written signatures. Director and site coordinator were reminded sign in/out sheets must be made available for review.

This facility plans to provide Incidental Medical Services – IMS. For IMS information, see PIN 22-02-CCP. 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) tollfree ADA Information Line at (800) 514-0301 (voice) or (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.

LPA reviewed with facility representatives, the LIC 311A, Records to Be Maintained At The Facility, for child’s records, personnel records, administrative records, and documents to be posted.

The requirement for Lead Water Testing was discussed (H&S Code 1597.16). Director was reminded a facility licensed after July 1, 2022, must have their water fixtures tested for lead 180 days after licensure and every 5 years thereafter. LPA advised director to review PIN 21-21-CCP.
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SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: YMCA SF-MARIN HEARTWOOD CHARTER SCHOOL	FACILITY NUMBER: 214005669
	VISIT DATE: 12/19/2023

NARRATIVE

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Facility representatives were reminded that all adults 18 and over responsible for administration or direct supervision of staff, persons who provides care and supervision to children, and staff who have contact with children, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.

Facility representatives were informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

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 platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-carelicensing/ subscribe and select the Child Care option to receive email communication.

LPA will approve for requested capacity of 100 school age children, when follow is completed:
-Fire clearance
-Installation of smoke/carbon monoxide detector.
-Phone number for YMCA program on site.
-All required licensing documentation properly posted (LIC610 and child passenger restraint)
-Submission of director packet for director of youth development.
-Applicant's signed LIC503 and required immunizations.
-LPA's review and approval of documents submitted.
-Management approval of outdoor area.

Exit interview conducted and report was reviewed with director of youth development, Jeanie Calagui.

SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

LIC809 (FAS) - (06/04)

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