<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414001934
Report Date: 08/25/2022
Date Signed: 08/25/2022 03:53:57 PM

Document Has Been Signed on 08/25/2022 03:53 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:SAN MATEO-FOSTER CITY SCHL DIST - PARK SCHOOLFACILITY NUMBER:
414001934
ADMINISTRATOR:SANDRA PHILLIPS-SVEDFACILITY TYPE:
850
ADDRESS:161 CLARK DRIVE, LG-1TELEPHONE:
(650) 312-7577
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 3DATE:
08/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Amy Gustas, Karrie HaseltonTIME COMPLETED:
04:00 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
On 8/25/2022 at 12:45PM., Licensing Program Analyst (LPA), Luis J. Gomez met with Teacher, Amy Gustas. Purpose of the inspection was explained and was for an unannounced; Annual/ Random inspection. Preschool program is located at San Mateo Park Elementary School. Present were two staff supervising three children. Children present had been properly signed in. Preschool program utilizes classroom: LG-1 and two outdoor play spaces (Patio and Kindergarten Yard). Hours of operation are Monday- Friday, 8:30am- 3:00pm. Principal Child Development, Karrie Haselton arrived during inspection. Program follows the 10- month, school district schedule. Personnel’s criminal record clearance is received through the school district. LPA inspected facility, indoors and outdoors, for health and safety hazards.

At 12:55P.M., LPA observed the following: Classroom was clean, orderly, and with a variety of age-appropriate playthings available for the children. Floors and ground surfaces were free of obstructions. Furniture, puzzles and accessible items were in proper repair. Classroom was equipped with hooks for storage of children’s belongings. Classroom had several child sized tables and chairs for snack and activities. Bathroom had adequate supplies for hand washing. Fixtures tested were operating condition. Staff restroom is located separately. For napping services, foldable mats are stored in the classroom. Per staff, napping supplies are washed weekly by families. Classroom had acceptable ventilation and lighting. Detergents; cleaning supplies; and toxins were stored inaccessible to children. Electrical outlets were covered. LPA reminded facility to ensure trash bins are covered. Classroom have functioning smoke detector/ carbon monoxide detector combo (Built-in) and fully charged fire extinguisher; 2A:10BC. First aid kit was reviewed during inspection.

At 1:20PM., LPA inspected the Kindergarten yard and Patio. Outdoor areas were enclosed with tall fencing. Outdoor spaces were observed free of debris or hazardous plants or objects. Play structure inspected were in good repair and properly anchored. Rubber cushioning had been installed around structure for added safety. Per Principal Child Development, refillable water bottle are brought outside by staff. LPA reminded facility to ensure all children water containers are labeled with child’s name. (REFER TO 809-C FOR CONT.)

SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2022
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 3
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: SAN MATEO-FOSTER CITY SCHL DIST - PARK SCHOOL
FACILITY NUMBER: 414001934
VISIT DATE: 08/25/2022
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 2)
At 1:35PM, LPA review facility records including seven children’s files and two personnel files. Staff files reviewed and included: Proof of Qualifications (Permit), Notice of Employee Rights (LIC9052), Proof of Required Immunization, and Declaration to Report Suspected Child Abuse (LIC9108).

LPA reminded facility to ensure staff’s updated mandated reporter certification are in the facility files.

Children’s files were reviewed, and included the: Consent for Medical Treatment (LIC627), Immunization Record, Identification of Emergency Information (LIC700), Health History, Personal Rights (LIC613A) and Notification of Parent’s Rights (LIC995).

Present staff member’s CPR/ 1st aid certification was current, expiring on: 06/30/2023.


Disaster drills are conducted every six months with the last drill done, 5/25/2022. LPA reminded facility to properly log all disaster drill conducted.

LPA observed required postings including: License, Waivers (Bathroom and Outdoor Space Waiver), Child Passenger Safety Laws Poster, Parents Rights (PUB393), Emergency Disaster Plan (LIC610). Per Principal Child Development, snacks and lunches are provided by families only. LPA reviewed children’s medication during inspection.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manuel – Regulations Interpretations and Procedures for Child Care Centers Section 101173 and 101226. When an IMS is provided, an updated Plan of Operations that includes IMS must be submitted to the Department. Following information regarding ADA was provided: US Department of Justice (USDOJ) toll- free ADA information line at (800) 514- 0382 (TTY) and link to publications: Commonly asked questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm (REFER TO 809C FOR CONT.)

SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022
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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: SAN MATEO-FOSTER CITY SCHL DIST - PARK SCHOOL
FACILITY NUMBER: 414001934
VISIT DATE: 08/25/2022
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 3)
Based on today's inspection, no deficiencies were observed in the areas evaluated according the Title 22 Division 12 Ca. Code of Regulations. Exit interview and report was reviewed with Teacher, Amy Gustas and signature of this form acknowledges receipt of these documents.

This report and rights to comment were discussed. This report must be available in the facility for public review. Notice was given and must remain posted for 30 days. Facility was advised any additional questions to call Office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website: www.ccld.ca.gov
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3