414005024-8-7-2023-05-CC-CQUO-CUGQCQ-20230807120331

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414005024
Report Date: 08/07/2023
Date Signed: 08/07/2023 12:03:38 PM

Document Has Been Signed on 08/07/2023 12:03 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 CARLOS-BELMONT AFTER SCHOOL		FACILITY NUMBER:	414005024
ADMINISTRATOR:	PERINO, ANTHONY		FACILITY TYPE:	840
ADDRESS:	3100 ST. JAMES ROAD		TELEPHONE:	(650) 591-8039
CITY:	BELMONT	STATE: CA	ZIP CODE:	94002
CAPACITY: 150	TOTAL ENROLLED CHILDREN: 0	CENSUS: 0	DATE:	08/07/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Anthony Perino & Elizabeth Benedict		TIME COMPLETED:	12:30 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 August 7, 2023 at approximately 8:30am, Licensing Program Analyst (LPA) Catrina Quimbo conducted a pre-licensing inspection. LPA met with applicants Anthony Perino and Elizabeth Benedict. The applicant is requesting a school age license for 150 children (TK to 5th grade). The facility will operate Monday through Friday morning sessions from 7:00am to 8:30am and after school sessions 12:00pm to 6:00pm. The program will operate at Fox Elementary School of San Carlos Belmont school district in Portable Classroom #1, Portable Classroom #2, Multi-purpose room and Library only. The designated director will be Anthony Perino. The facility was inspected, indoors and outdoors, for health and safety hazards. The school age program is exempt from requirements for indoor and outdoor square footage, fencing, and toilet/sink ratios. No measurements were taken during LPA's visit. Indoors: The main classroom for after school program will be Portable Classroom #1. Applicants plan for Portable Classroom #1 to be for TK and Kindergarten children while Portable Classroom #2 will be for children 1st grade to 3rd grade. The library will be utilized for homework purposes for 3rd grade to 5th grade children. The multi-purpose room will be used for multiple purposes. LPA observed portable classrooms to be equipped with appropriate furniture that is in good working condition. Toys and materials were observed to be appropriately stored and maintained. There is a refrigerator, stove and food prep area for staff use only. Per applicants, when stove is in use, children will not be permitted to enter portable classroom. Both portable classrooms were observed to have fire extinguishers and a fire alarm system implemented by the school district. LPA observed portable classroom to have a working carbon monoxide detector. Portable classrooms are also equipped with fully stocked first aid kits. Medications with required documentation will be stored in portable classrooms' high shelves, inaccessible to children. Medication that require refrigeration will be stored in a locked box in refrigerator located in portable classroom. (Continue Report on Page 2...)

SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2023

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: SAN CARLOS-BELMONT AFTER SCHOOL	FACILITY NUMBER: 414005024
	VISIT DATE: 08/07/2023

NARRATIVE

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Portable classrooms also include two bathrooms that is exclusive for children's use. LPA observed bathrooms to be in proper working condition. Children also have access to the bathrooms in the multi-purpose area (labeled "boys" and girls" rooms). Program does not have access to classrooms in multi-purpose area. Restrooms were observed to be clean and in proper working condition, and allow for individual privacy.

Applicants plan for toxins, poisons and other hazardous items to be stored in portable classrooms' high shelves, inaccessible to children in care. Both Portable classroom #1 and #2 will have an isolation area for sick children, separate from other enrolled children. Applicant plans to utilize a cot and couch for sick children when needed. LPA observed classrooms to have garbage bins with tight fitting lids.

Program will provide a morning breakfast and afternoon snacks only. Per applicants, food will be stored in a designated cabinet that does not contain toxins or poisons. Water is accessible to enrolled children with multiple refillable water stations and water fountains on site.

Outdoors: The entire outdoor area of the school is enclosed by a fence that is at least four feet tall. After school program has access to entire outdoor area that includes black tops, baseball field, three playgrounds and bench/lunch tables.

LPA observed all three playgrounds to be in proper working condition, with resilient padding underneath. Playground #1 (located closest to portable classrooms) was observed to be age appropriate. Playground #2 (located on baseball field) will be utilized for 3rd to 5th grade children only. Playground #3 (located behind library) will be utilized for TK to Kindergarten children. LPA observed playgrounds and outdoor area to be clean, safe and free of any loose articles or materials. Shade is made available with adjacent buildings, trees and large tarp.

Applicants are aware children must always be supervised and monitored on the playgrounds. Applicants are also aware children must always be supervised going to and from the restroom, playground areas, portable classrooms, library and multi-purpose area. Program's discipline policy will be to communicate with children and removing them from the situation.

Applicants are aware disaster drills are conducted and must be properly logged. Licensing documentation and posters will be posted in portable classroom #1. Children will be signed into program by after school's staff and will be signed out of program by children's authorized representatives' written signatures. Applicants are aware sign in/out sheets must be made available for review.
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SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2023

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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SAN CARLOS-BELMONT AFTER SCHOOL	FACILITY NUMBER: 414005024
	VISIT DATE: 08/07/2023

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This facility plans to provide Incidental Medical Services – IMS. For IMS information, see PIN 22-02-CCP. A Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) tollfree 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, available at: http://www.ada.gov/childqanda.htm.

LPA reviewed with applicants, the LIC 311A, Records to Be Maintained At The Facility, for child’s records, personnel records, administrative records, and documents to be posted.

The requirement for Lead Water Testing was discussed (H&S Code 1597.16). Applicant was reminded a facility licensed after July 1, 2022, must have their water fixtures tested for lead 180 days after licensure and every 5 years thereafter. LPA advised applicant to review PIN 21-21-CCP.

Applicants were reminded that all adults 18 and over responsible for administration or direct supervision of staff, persons who provides care and supervision to children, and staff who have contact with children, 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.

Applicants were informed of the MyChildCarePlan.org site, 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.

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 platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-carelicensing/ subscribe and select the Child Care option to receive email communication.

Prior to recommended licensure, following must be completed:
-Fire clearance.
-LPA's review and approval of documents resubmitted.

Exit interview conducted and report was reviewed with applicants, Anthony Perino and Elizabeth Benedict.

SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2023

LIC809 (FAS) - (06/04)

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