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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410517924
Report Date: 05/14/2024
Date Signed: 05/14/2024 05:51:29 PM

Document Has Been Signed on 05/14/2024 05:51 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:PENINSULA COVENANT CHURCH AFTERCAREFACILITY NUMBER:
410517924
ADMINISTRATOR/
DIRECTOR:		CARRION, MEGANFACILITY TYPE:
840
ADDRESS:3560 FARM HILL BLVD.TELEPHONE:
(650) 365-8094
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY: 140TOTAL ENROLLED CHILDREN: 69CENSUS: DATE:
05/14/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Susan LinkwitzTIME VISIT/
INSPECTION COMPLETED:
06:15 PM
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On May 14, 2024, at @ 1:00pm Licensing Program Analyst (LPA) Maria Olguin-Leon met with Program Manager, Susan Linkwitz for an unannounced annual inspection. Purpose of inspection was explained. Present today, Director, Program Manager, 6 staff and school age children. Facility is operating within capacity and in compliance with staff child ratio. LPA observed staff did not have criminal background clearance, this poses an immediate risk to children in care. A type A violation was cited today for this deficiency. Facility operates after-school program from Monday to Friday 11:00am-6:00pm and 8:00am – 5:00pm during the summer.

LPA and Program Manager toured the facility for health and safety hazards. Facility operates an after-school program in three groups in three main spaces on the site Peninsula Covenant Church. Program utilizes the fellowship hall, three rooms in the children’s building (rooms #1, #2 and #15), two room (rooms #106 & #301) and gym at the community center. Other rooms are not currently being utilizes are room #104 in Community Center and room #3 in children’s building. Classrooms are clean with proper ventilation. There are plenty of age-appropriate toys/games, art/crafts material, furniture and learning materials all in good repair. Children’s belongings are stored in classroom #15 in cubbies and on hooks. All trash containers have tight fitting lids. There are separate boys and girl’s bathroom in each main space. LPA observed toilets are all in working condition and working sinks have no running hot water. There is a separate staff bathroom. Facility uses two playgrounds; kindergarten share preschool playground. Playground is located in lower part of facility and is accessible across walking bridge. Playground is equipped with a large age-appropriate play structure, sensory water/sand table and tables, all in good condition. There is a locked storage shed with first aid box and outdoor toys. Playground is surrounded with a 5 ft. fence. Flooring under play structure is equipped with sand to cushion fall and remainder of flooring is asphalt. Playground for older children is located across kindergarten playground and is equipped a large play structure and a swing set. Playground flooring is rubber to cushion falls. LPA did not observe any pools or bodies of water were observed.

Cont. on page 2…
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Maria Olguin-Leon
LICENSING EVALUATOR SIGNATURE: DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: PENINSULA COVENANT CHURCH AFTERCARE
FACILITY NUMBER: 410517924
VISIT DATE: 05/14/2024
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After school program provides snacks for children in care. Food is properly stored and labeled in cabinets and refrigerator to avoid contamination. Children bring their own labeled water bottles and water is refilled with water faucets. There is a fully equipped first aid kit and Incidental Medical Services were discussed. Isolation area for sick children is collaboration room and away from other children. All cleaning products, chemicals, and toxins are inaccessible to children and locked in storage cabinets. LPA reviewed sign in/out sheets; LPA reminded facility to have full signatures. Staff sign in children into after school and parents sign children out. Classrooms are equipped with smoke alarms, carbon monoxide detector and fully charged fire extinguisher. Facility has a landline and staff use walkie talkies to communicate with each other.

LPA reviewed 5 children’s records and 5 staff record. The facility has all necessary paperwork posted and includes Facility License, Notification of Parent's Rights, Notification of Personal Rights, Car Seat Law, and Emergency Disaster Plan. Last emergency drill was conducted on 03/13/2024 and properly documented. Per Director there are no firearms or weapons on site.

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/.

Director was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Cont. page 3...
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Maria Olguin-Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
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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: PENINSULA COVENANT CHURCH AFTERCARE
FACILITY NUMBER: 410517924
VISIT DATE: 05/14/2024
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The Director was reminded about the Provider Information Notices (PINs) on the CCLD website. Licensee was informed that as of September 1, 2016, a person may not be employed or volunteer at a childcare facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662.

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.

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

LPA reviewed AB 1207 with the Licensee. As of January 1, 2018, all staff must complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process

Cont. page 4....
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Maria Olguin-Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
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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: PENINSULA COVENANT CHURCH AFTERCARE
FACILITY NUMBER: 410517924
VISIT DATE: 05/14/2024
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*** THIS IS AN AMENDMENT OF ORIGINAL REPORT DATED 05/14/24.***

See page 809D for details of Type B violations issued today. Appeal Rights were provided to Director.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with Director and Program Manager, Meredith McLean and Susan Linkwitz.
SUPERVISORS NAME: Carol Marcroft
LICENSING EVALUATOR NAME: Cindy Interiano
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
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Document Has Been Signed on 09/11/2024 02:32 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 09/11/2024 02:24 PM


Created By: Cindy Interiano On 05/14/2024 at 05:08 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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PENINSULA COVENANT CHURCH AFTERCARE
FACILITY NUMBER: 410517924

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
HSC
1596.871(c)(1)(A)
Administration of Child Day Care Licensing
Subsequent to initial licensure, a person specified in subdivision (b) who is not exempt from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification, pursuant to subdivision(f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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***THIS IS AN AMENDMENT OF ORIGINAL REPORT DATED 05/14/24***
***Deficiency has been modified from a TYPE A violation to a TYPE B violation.***
Based on record review and interview, staff did not have criminal background completed via Guardian. This poses a potential health, safety, or personal rights risk to the persons in care.
POC Due Date: 05/15/2024
Plan of Correction
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All staff will have criminal background clearance completed immediately and associated with facility via Guardian
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Carol Marcroft
LICENSING EVALUATOR NAME:Cindy Interiano
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2024


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Document Has Been Signed on 05/14/2024 05:51 PM - It Cannot Be Edited


Created By: Maria Olguin-Leon On 05/14/2024 at 05:08 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: PENINSULA COVENANT CHURCH AFTERCARE
FACILITY NUMBER: 410517924

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2024

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 and interview, the facility has not completed lead testing. This posed a potential health, safety, or personal rights risk to the persons in care.
POC Due Date: 06/14/2024
Plan of Correction
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Per Program Manager, facility is waiting to hear back from company to schedule lead testing.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Marie Rodriguez
LICENSING EVALUATOR NAME:Maria Olguin-Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2024


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