384001816-6-6-2024-05-CC-JTSE-D5YQ8F-20240606115640

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 384001816
Report Date: 06/06/2024
Date Signed: 06/06/2024 11:56:59 AM

Document Has Been Signed on 06/06/2024 11:56 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:	PACIFIC PRIMARY - ORANGE SUN CAMPUS		FACILITY NUMBER:	384001816
ADMINISTRATOR:	STANCIL, MADONNA-DIRECTOR		FACILITY TYPE:	850
ADDRESS:	1501 GROVE STREET		TELEPHONE:	(415) 409-1961
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94117
CAPACITY:	75	CENSUS: 66	DATE:	06/06/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Director, Madonna Stancil		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 6/6/2024, at approximately 8:50AM, Licensing Program Analyst (LPA) Jonathan Tse conducted an unannounced annual visit at the facility. LPA met with Director Madonna Stancil (D1). LPA explained the purpose of the visit. Present during the visit was D1, 14 staff members, and 66 preschool age children. The facility is in compliance with staffing and ratio requirements on this day. LPA inspected the facility for any health or safety hazards. There are fully charged 2A10BC fire extinguishers present throughout the facility. There are operational carbon monoxide detectors present. There is a fire alarm system running in the facility. Evacuation routes are posted and accessible in each room. Emergency exits are clearly marked and visible. Poisons, cleaning detergents, and other chemicals are stored inaccessible to children in care. The facility has four classrooms: Penguins, Prairie Dogs, Pandas, and Polar Bears. LPA observed age-appropriate toys and learning materials to be present in each classroom. Children have access to two sinks and two operational toilets in each classroom. There are cubbies available for each child in care. Allergy lists are posted and accessible for teachers to reference. Each classroom is equipped with a fully stocked first aid kit. Children nap on mats that are provided by the facility. Bedding and blankets are brought from home and taken back once a week for cleaning. Children bring water bottles from home and the facility provides refills from a non-contaminating source. Waste bins are fitted with tight-fitting lids. There is a movement room and an art room available for groups of four to twelve children at a time. LPA observed the facility kitchen to be in clean and orderly condition. LPA observed milk and food to be labeled and stored appropriately. All food items observed in the kitchen were checked for expiration dates. Continued on Page Two

SUPERVISOR'S NAME: Ali Zebila	TELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Jonathan Tse	TELEPHONE: (650) 464-4927
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 5

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: PACIFIC PRIMARY - ORANGE SUN CAMPUS	FACILITY NUMBER: 384001816
	VISIT DATE: 06/06/2024

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
26
27
28
29
30
31
32

Page Two
The facility has an outdoor rotation waiver that allows for up to 25 children to be present in the outdoor play area at a time. LPA observed the facility to be in compliance with the waiver during the visit. There are age-appropriate toys and equipment present for children in care. There are no pools or other bodies of water present in the facility.

LPA reviewed six staff files, six children’s files, and facility records. LPA observed that all staff members have qualifications and immunization records available for review. LPA advised that the facility shall check and maintain a current staff roster on Guardian. LPA observed that the First Aid/CPR training that staff members have completed was not EMSA certified. See LIC809-D for deficiency cited today. LPA observed all children’s files to be complete. LPA observed all required postings to be posted and accessible for review immediately upon entry to the facility. LPA observed the facility menu and daily activity schedule to be posted and accessible for review. The facility tested its fixtures for lead on 10/22/2022. There were no exceedances of lead in any of the fixtures tested. LPA advised that sinks used only for handwashing do not need to be tested. 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.

Continued on Page Three

SUPERVISOR'S NAME: Ali Zebila	TELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Jonathan Tse	TELEPHONE: (650) 464-4927
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2024

LIC809 (FAS) - (06/04)

Page: 2 of 5

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: PACIFIC PRIMARY - ORANGE SUN CAMPUS	FACILITY NUMBER: 384001816
	VISIT DATE: 06/06/2024

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
26
27
28
29
30
31
32

Page Three
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 verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of “medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. 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-carecenters/.

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 deficiency cited today regarding Pediatric First Aid/CPR certification. See LIC9102-TV for technical violation issued today regarding maintaining a current roster on Guardian.

Appeal rights were provided and explained. 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, Madonna Stancil.

SUPERVISOR'S NAME: Ali Zebila	TELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Jonathan Tse	TELEPHONE: (650) 464-4927
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2024

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 06/06/2024 11:56 AM - It Cannot Be Edited

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: PACIFIC PRIMARY - ORANGE SUN CAMPUS	FACILITY NUMBER: 384001816
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101216(f)

Personnel Requirements

(f) At least one staff member who is trained in pediatric cardiopulmonary resuscitation and pediatric first aid pursuant to Health and Safety Code Section 1596.866 shall be present when children are at the child care center or offsite for center activities. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above by not enrolling staff for an EMSA certified training course which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/28/2024
	Plan of Correction
1 2 3 4	Licensee shall provide proof of enrollment in an EMSA certified Pediatric First Aid/CPR training course to LPA by set due date of 6/28/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Jonathan Tse	TELEPHONE: (650) 464-4927
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2024

LIC809 (FAS) - (06/04)

Page: 4 of 5