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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380505313
Report Date: 06/12/2024
Date Signed: 06/12/2024 03:51:32 PM

Document Has Been Signed on 06/12/2024 03:51 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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:MIRALOMA NURSERY SCHOOLFACILITY NUMBER:
380505313
ADMINISTRATOR/
DIRECTOR:		ROSE SHANNONFACILITY TYPE:
850
ADDRESS:443 FOERSTER STREETTELEPHONE:
(415) 585-6789
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94127
CAPACITY: 22TOTAL ENROLLED CHILDREN: 18CENSUS: 7DATE:
06/12/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Director, Rose ShannonTIME VISIT/
INSPECTION COMPLETED:
04:05 PM
NARRATIVE
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On 6/12/2024, at approximately 1:30PM, Licensing Program Analyst (LPA) Jonathan Tse conducted an unannounced annual visit. LPA met with Director Rose Shannon (D1) and explained the purpose of the visit. Present during the visit was D1, one teacher, and seven preschool age children. All adults working in the facility have acquired fingerprint clearance and are associated to the facility. The facility is in compliance with staffing and ratio requirements on this day. The facility is a parent cooperative program that runs from 8:30AM to 12:30PM. Extended care is from 12:30PM to 3:30PM.

LPA inspected the facility for any health or safety hazards. LPA observed the facility to be in clean and orderly condition. The facility is equipped with fully charged fire extinguishers that are at least size 2A10BC. There are operational carbon monoxide and smoke detectors present. Emergency exit routes are posted and visible in the facility. Poisons, cleaning detergents, and other chemicals are stored inaccessible to children in care.

LPA observed there to be age-appropriate toys and learning materials. Furniture is age-appropriate and free of rough or sharp edges. Children have access to manipulatives, books, and art supplies. There is a loft present that is secured with railings. There are two toilets and two sinks that were demonstrated to be operational during the visit. There are cubbies available for each child in care. The facility provides cots for children to nap during extended care. Children bring bedding and blankets from home and take them back once a week for cleaning. Children bring lunch and snacks from home. The facility has snacks available for children. Children bring water bottles from home and the facility refills the bottles from a non-contaminating fixture.



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SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE: DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2024
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: MIRALOMA NURSERY SCHOOL
FACILITY NUMBER: 380505313
VISIT DATE: 06/12/2024
NARRATIVE
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LPA observed the outdoor play area to be free of debris and other loose articles. There are age-appropriate play structures and equipment present. There is resilient padding in the form of sand. There is shade available from trees that are present. There are no pools or other bodies of water present in the facility.

LPA reviewed four staff files, five children’s files, and facility records. There is at least one staff member with current Pediatric First Aid/CPR training. LPA observed that there are no current Mandated Reporter Training certificates present. LPA discussed Mandated Reporter Training requirements with D1. D1 stated that they understood. LPA observed all children’s files to be complete. Children are signed in via the Brightwheel app. The facility last conducted an emergency drill on 5/15/2024.

Based on review of the facility’s lead testing records, LPA observed that lead testing was conducted on 8/1/2023, past the deadline of 1/1/2023. There was no exceedance of lead in the outlet that was tested. LPA discussed lead testing requirements with D1 during the visit. D1 stated that they understood.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

Facility representative was reminded that all adults 18 and over, 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.





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SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
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: MIRALOMA NURSERY SCHOOL
FACILITY NUMBER: 380505313
VISIT DATE: 06/12/2024
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Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test. For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP).

LPA referred the facility representative to the Department website for lead: Lead Toxicity Prevention and Water Testing Information.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, an updated 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) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care
Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

Facility representative was informed of the MyChildCarePlan.org website; 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.

See LIC809-D for deficiencies cited today regarding lead water testing and Mandated Reporter Training. The deficiency cited regarding lead water testing shall be cleared on the same day of the visit, 6/12/2024. See LIC9102-TV for technical violation issued today regarding immunization records for staff.

Appeal rights were provided and explained to D1. A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the facility representative, Rose Shannon.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/12/2024 03:51 PM - It Cannot Be Edited


Created By: Jonathan Tse On 06/12/2024 at 03:32 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MIRALOMA NURSERY SCHOOL
FACILITY NUMBER: 380505313

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.16(a)(1)
Lead Testing
(1) A licensed child day care center, as defined in Section 1596.76, that is located in a building that was constructed before January 1, 2010, shall have its drinking water tested for lead contamination levels on or after January 1, 2020, but no later than January 1, 2023, and every five years after the date of the initial test.

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 by testing fixtures for lead before the deadline of 1/1/2023 which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2024
Plan of Correction
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The facility tested its fixtures for lead on 8/1/2023 with no exceedances of lead. This deficiency shall be cited and cleared the same day of the visit, 6/12/2024.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

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 in three staff files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2024
Plan of Correction
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The facility shall have its staff complete Mandated Reporter Training by set due date of 6/28/2024. The facility shall submit proof of completion to LPA via email.
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:Ali Zebila
LICENSING EVALUATOR NAME:Jonathan Tse
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024


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