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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414001934
Report Date: 11/16/2023
Date Signed: 11/16/2023 01:44:35 PM

Document Has Been Signed on 11/16/2023 01:44 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:SAN MATEO-FOSTER CITY SCHL DIST - PARK SCHOOLFACILITY NUMBER:
414001934
ADMINISTRATOR:CRISTINA HALEYFACILITY TYPE:
850
ADDRESS:161 CLARK DRIVE, LG-1TELEPHONE:
(650) 312-7577
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 10DATE:
11/16/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Amanda DriscollTIME COMPLETED:
01:45 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 11/16/2023 at 8:45AM., Licensing Program Analysts (LPA) Luis J. Gomez met with Karrie Hasselton. Principal, Amanda Driscoll arrived during inspection. Purpose of inspected was for Case Management for an Increase of Capacity/ Room Addition. Purpose of this report is to cite facility for deficiencies observed today's inspection. Present during inspection was the principal and 3 staff caring for 10 children. LPA inspected facility for health and safety hazards.

At 1:15PM., Based on record review and interviews, LPA confirmed facility’s drinking water has not been tested for lead contamination levels.



Based on today’s inspection, deficiencies were observed in areas evacuated according to the Title 22, Division 12, Chap, 1 of Ca, Code of Regulations and cited on the 809D. An exit interview, report, appeal rights, and plan of correction was discussed with the Principal, Amanda Driscoll and signature of this form acknowledges the receipt of these documents.

A copy of this report and appeal rights were reviewed and provided to the Director.
Notice of site visit was given and shall remain posted for 30 days.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2023
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 2
Document Has Been Signed on 11/16/2023 01:44 PM - It Cannot Be Edited


Created By: Luis Gomez On 11/16/2023 at 01:17 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: SAN MATEO-FOSTER CITY SCHL DIST - PARK SCHOOL
FACILITY NUMBER: 414001934

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/27/2023
Section Cited
CCR
1597.16(a)(1)

1
2
3
4
5
6
7
1597.16(a)(1) Written Directives. 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:
1
2
3
4
5
6
7
Director will ensure fixtures used for drinking water are tested and results are submitted to the department by the due date: 11/27/2023.
8
9
10
11
12
13
14
At 1:15PM., Based on record review and interviews, LPA confirmed facility’s drinking water has not been tested for lead contamination levels. This poses a potential health and safety risk to children in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Luis Gomez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2