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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414002663
Report Date: 04/11/2024
Date Signed: 04/11/2024 02:10:43 PM

Document Has Been Signed on 04/11/2024 02:10 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:IMMACULATE HEART OF MARY (PRESCHOOL)FACILITY NUMBER:
414002663
ADMINISTRATOR:
ADMINISTRATOR/
DIRECTOR:		ARBAN, ERSIEFACILITY TYPE:
850
ADDRESS:1000 ALAMEDA DE LAS PULGASTELEPHONE:
(650) 593-4265
CITY:BELMONTSTATE: CAZIP CODE:
94002
CAPACITY: 36TOTAL ENROLLED CHILDREN: 12CENSUS: 9DATE:
04/11/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
TIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Ersie ArbanTIME COMPLETED:
TIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On April 11th, 2024, Licensing Program Analyst (LPA) Kassandra Medrano met with Ersie Arban, Site Supervisor, for an unannounced required –annual inspection. LPA toured the indoor and outdoor areas of the facility during today's inspection. LPA observed the required posted materials, including the Facility License, Emergency Disaster Plan (LIC 610), Earthquake Preparedness Checklist (LIC 9148), Parents' Rights Poster (PUB 393), Personal Rights (LIC 613A), Child Car Seat Law (PUB 269), menus, and Activity Schedule. Days and hours of operation are Monday through Friday: 8am-6pm. The preschool age program is Licensed in Rooms 1 and 2. Facility is on the campus of Nativity Catholic school campus, which is a private school. During inspection it was observed at 9:05am children were taken to PE which took place in gymnasium, this space has not been approved for use. Present in the facility were 9 preschool aged children, and 2 staff. LPA observed that the teacher/child ratio was in compliance during today's inspection. The following was observed today: LPA reviewed 12 children's and 3 staff files during today's inspection. During review, it was observed that 1/3 staff was missing documentation of MMR and 2/3 are missing current influenza or the declination. During file review it was observed that 2/3 staff are missing Mandated Reporter Training for Child Care Workers. The staff files that were reviewed have current CPR and First Aid certifications on file. Director understands that there shall be at least one person, with valid CPR and First Aid certifications, on site at all times or present during off-site activities (field trips). During review off children’s files, it was observed that children’s files are complete and up to date. Director understands the conditions, limitations, and capacity specifications of the facility license. Director understands that children shall be always visually supervised. Any child(ren) who exhibit symptoms of illness including, but not limited to, fever or vomiting, are not accepted in care. Any child(ren) who become ill during the day, shall be isolated in the director’s office. 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/.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Kassandra Medrano
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2024
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: IMMACULATE HEART OF MARY (PRESCHOOL)
FACILITY NUMBER: 414002663
VISIT DATE: 04/11/2024
NARRATIVE
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LPA observed that the Facility is clean, safe, sanitary, and in good repair for children, staff, and visitors. The Facility has adequate ventilation, including central air conditioning/heating. Director understands that the Facility must be kept free of flies and other insects & rodents. LPA observed that all furniture and equipment is in good condition and safe for the children. Drinking water is readily available for the children in the Facility and in the outdoor playground area via personal water bottles that are typically filled at home, but if the water runs out facility refills with plastic water bottles. Staff and children's bathrooms are clean, sanitary, and operable. 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 childcare 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). CCC DID NOT COMPLETE TESTING PRIOR TO THEIR DEADLINE, LPA referred facility representative to the Department website for lead: Lead Toxicity Prevention and Water Testing Information. Site supervisor states that there are no weapons or firearms on the premises. The Facility has functioning carbon monoxide detectors in the Facility. The food preparation and storage areas are clean, free of litter & rubbish, and free of rodents and other vermin. The facility only provides AM snack, and children's lunches are brought from home. Lunches are stored in personal lunch boxes that are within the child's individual cubby. The Facility has trash cans with tight fitting lids for solid waste. Cleaning supplies are inaccessible to the children and stored in high cabinets inaccessible to children. LPA observed a complete First Aid kit in the Facility, including a touch less thermometer. Director understands that smoking is not allowed on the Facility premises. Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication. The playground area utilized by children is surrounded by appropriate fencing and the outdoor surfaces are safe for the children. LPA observed that the outdoor equipment is age appropriate and in good condition. Shade is provided by trees and building overhangs in the playground. LPA did not observe any bodies of water. The playground is shared by the kindergarten, and the facility uses a rotational schedule to ensure that preschool and kindergarten programs do not commingle. Director states that the Facility does not provide transportation.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Kassandra Medrano
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
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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: IMMACULATE HEART OF MARY (PRESCHOOL)
FACILITY NUMBER: 414002663
VISIT DATE: 04/11/2024
NARRATIVE
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LPA discussed the safe sleep regulations with facility representative and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed facility representative of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment. Ersie, site supervisor, 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.
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.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Site Supervisor, Ersie.

California Code of Regulations, Title 22 deficiencies are being cited on the following pages:
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Kassandra Medrano
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 04/11/2024 02:10 PM - It Cannot Be Edited


Created By: Kassandra Medrano On 04/11/2024 at 01:36 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: IMMACULATE HEART OF MARY (PRESCHOOL)
FACILITY NUMBER: 414002663

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2024

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 interview and record review, the licensee did not comply with the section cited above by not completing required lead testing by or before january 1,2023 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2024
Plan of Correction
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4/11/24 During visit Andrea Harville, Prinicipal contacted water sampler to initiate process. Facility to complete and have results posted as POC. If the testing is not complete by deadline or action level exceedance is found facility must request an extension for plan of correction.
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 on 4/11/24, the licensee did not comply with the section cited above in which S1 and S2 were missing updated certificates which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2024
Plan of Correction
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Site supervisor to send certificates for S1 and S2 via email or in person.
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:Kassandra Medrano
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 04/11/2024 02:10 PM - It Cannot Be Edited


Created By: Kassandra Medrano On 04/11/2024 at 01:36 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: IMMACULATE HEART OF MARY (PRESCHOOL)
FACILITY NUMBER: 414002663

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review on 4/11/24, it was found that S2 was missing documentation MMR and updated influenza, as well as S3 was missing current influenza which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2024
Plan of Correction
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Site supervisor to send documentation of updated immuizations via email or in person
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:Ali Zebila
LICENSING EVALUATOR NAME:Kassandra Medrano
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024


LIC809 (FAS) - (06/04)
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