435700753-10-13-2022-52-CC-MOTI-CK6PYF-20221013114350

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435700753
Report Date: 10/13/2022
Date Signed: 10/13/2022 11:44:09 AM

Document Has Been Signed on 10/13/2022 11:44 AM - 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME:	PALO VERDE KIDS' CLUB		FACILITY NUMBER:	435700753
ADMINISTRATOR:	ANDRADE, ROCIO		FACILITY TYPE:	840
ADDRESS:	4000 MIDDLEFIELD ROAD		TELEPHONE:	(650) 493-2361
CITY:	PALO ALTO	STATE: CA	ZIP CODE:	94306
CAPACITY: 60	TOTAL ENROLLED CHILDREN: 60	CENSUS: 0	DATE:	10/13/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:57 AM
MET WITH:	Rocio Andrade		TIME COMPLETED:	11:50 AM

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	An unannounced Prelicensing inspection was conducted today, 10/13/2022, by Licensing Program Analyst (LPA) Melanie Otsuji with Director, Rocio Andrade. An application was submitted for a Temporary Relocation of a School Age program. The facility has temporarily moved from 3450 Louis Road, Palo Alto to 4000 Middlefield Road, Palo Alto. Facility resides on the campus of Cubberley Community Center in room M4. Facility will return (anticipated to be Fall 2023) to previous campus upon construction completion. Upon completion of the construction, the applicant will contact Licensing prior to re-opening the center. The program will operate Monday through Friday from 11:25am to 6pm and during school breaks facility will operate from 7AM-6PM. A health and safety inspection was conducted inside and outside this facility is exempt from the indoor measurement and outdoor square footage requirements, the fencing requirements, toilet/sink ratios and isolation area requirements. The staff will use the bathroom near the Pavillion N which will also be used as isolation area for sick children. There are no bodies of water nor any firearms or weapons on the premises. Storage for cleaning supplies are locked and made inaccessible to children. Furniture and equipment are free of any hazards. The classroom is equipped with age appropriate materials and equipment. There is a carbon monoxide detector, smoke detector, and fire extinguishers are available all throughout the center. Heating, lighting, and air conditioner are adequate. First Aid Kit is available. Each child has individual storage for their belongings. The children will utilize the grassy area outside of the building. On occasion the facility will utilize the elementary schools playground. Center has a water dispenser to refill children's water bottles. The facility will provide am/pm snacks. Facility has provided a complete director qualification packet and Director will be, Rocio Andrade. Licensing Board is available with required postings. Facility received an approved fire clearance from Palo Alto Fire Department on 10/05/2022. ----------------------------------------------- CONTINUED ON PAGE 2 --------------------------------------------------------------

SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Melanie Otsuji
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: PALO VERDE KIDS' CLUB	FACILITY NUMBER: 435700753
	VISIT DATE: 10/13/2022

NARRATIVE

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This facility plans to provide Incidental Medical Services – IMS. For IMS information, see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. 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) toll-free ADA Information Line at (800) 514-0301 (voice)/ (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. 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.

A license for 60 school aged children operating out of classroom M4 in building M will be issued effective today's date, 10/13/2022.

An exit interview was conducted with Director, Rocio Andrade.

SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Melanie Otsuji
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

LIC809 (FAS) - (06/04)

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