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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435700765
Report Date: 08/24/2023
Date Signed: 08/24/2023 11:38:22 AM

Document Has Been Signed on 08/24/2023 11:38 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:HOOVER KIDS' CLUBFACILITY NUMBER:
435700765
ADMINISTRATOR:MOUTHAL, NATHALIEFACILITY TYPE:
840
ADDRESS:4000 MIDDLEFIELD RD., ROOM #M4TELEPHONE:
(650) 565-8847
CITY:PALO ALTOSTATE: CAZIP CODE:
94306
CAPACITY: 60TOTAL ENROLLED CHILDREN: 60CENSUS: 0DATE:
08/24/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Nathalie MouthalTIME COMPLETED:
11:50 AM
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An Announced Prelicensing inspection was conducted today, 8/24/2023, by Licensing Program Analyst (LPA) Melanie Otsuji with Director, Nathalie Mouthal. An application was submitted for a Temporary Relocation of a School Age program. The facility has temporarily moved from 445 East Charleston 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 2025) 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 11:45am to 6pm and during school breaks facility will operate from 8AM-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, Nathalie Mouthal. Licensing Board is available with required postings.

Facility received an approved fire clearance from Palo Alto Fire Department on 8/17/2023.

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SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Melanie Otsuji
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2023
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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: HOOVER KIDS' CLUB
FACILITY NUMBER: 435700765
VISIT DATE: 08/24/2023
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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. When any IMS is provided, an updated 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) 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 Applicant the LIC 311A, Records to Be Maintained At The Facility, for child’s records, personnel records, administrative records, and documents to be posted.

Director was 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-care-licensing/subscribe and select the Child Care option to receive email communication.

Exit interview conducted and report was reviewed with the Director, Nathalie Mouthal.

A license for 60 school aged children operating out of classroom M4 in building M will be issued effective today's date, 8/24/2023.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Melanie Otsuji
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
LIC809 (FAS) - (06/04)
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