Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380504419
Report Date: 01/05/2017
Date Signed: 01/31/2017 01:57:34 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:SFUSD-JEFFERSON EARLY EDUCATION SCHOOL-PRESCHOOLFACILITY NUMBER:
380504419
ADMINISTRATOR:WONG, DANNYFACILITY TYPE:
850
ADDRESS:1350 - 25TH AVENUETELEPHONE:
(415) 759-2852
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94122
CAPACITY:56CENSUS: 31DATE:
01/05/2017
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
03:33 PM
MET WITH:Liang, Xiao Min ( June ), Danny WongTIME COMPLETED:
03:34 PM
NARRATIVE
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LPA Ng conducted an unannounced random visit to the facility at issue. LPA met with Liang, Xiao Min, Head teacher and the Danny Wong, the new director for the facility, The director states that there are no known weapons or guns within the facility. Facility is a preschool program center. Rooms 1 and the bungalow is used for the preschool program. There were 31 children with 5 staff members. The facility operates 2 rooms. Furniture and equipment are age appropriate and in good repair. There is adequate heating, lighting and ventilation. Drinking water is readily available via water fountains and there is sufficient storage available for the children's belongings and sufficient space for the group size being served. Carbon Monoxide detectors were observed and tested to be working. There are separate toilet and sinks available for staff & children. There are sufficient cots for each child, the bedding is cleaned weekly. Proper staffing ratios are maintained. Regarding bathrooms, toilets flushed, faucets work, toilets and sinks are reachable by children. Toilet paper, soap and towels are available and the bathrooms are clean. There is sufficient lighting and ventilation. Hot water was measured at 73 degrees F. In regards to food service, the school provides Breakfast, lunch, and snack to the children. The food is prepared off site at a central kitchen. There is a food prep kitchen area the, the food was inspected for freshness and all items were in compliance. The refrigerator was operating at 36 degrees F. The menu is posted. In, inspecting the outside space, there are ample toys and activities for children. The facility has an outdoor area. The outdoor area has two play structures, the structures were observed to be in good condition. The flooring material is of soft rubber matting. In regards to health services, the site director states medications may be dispensed if a parent provides a note and does not need to be a prescription, it can be a over the counter medication. Medication is stored in the classrooms stored in locked back packs and hung inaccessible to children. Children are greeted and checked for illness and the director states that all children are now required to be immunized before entering the program. There are first aid supplies and thermometer available. There are Earthquake emergency items available. Isolation is provided in the office with the use of the staff bathroom if needed. Director states that it was required that all staff had completed immunization's before August 15, 2016. No children are on medication currently. In regards to records, facility has posted the required forms (i.e. License, menus, waivers, Notification of Parent's Rights (updated), Notification of Personal Rights, Car Seat Law (updated), and Emergency Disaster Plan).
SUPERVISOR'S NAME: Suzanne Roman-ClarkTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Tony NgTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2017
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 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: SFUSD-JEFFERSON EARLY EDUCATION SCHOOL-PRESCHOOL
FACILITY NUMBER: 380504419
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/06/2017
Section Cited
101238(a)
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101238(a) Buildings and Grounds. The child care center shall be clean, safe, sanitary and in good repair at all times.
( Kitchen Door left open )
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Facility must make all areas that are off limits inaccessible to children at all times. Provide for signage to inform staff to close the door when unoccupied, discuss at staff meeting, provide attendence document for staff meeting.
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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: Suzanne Roman-ClarkTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Tony NgTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2017
LIC809 (FAS) - (06/04)
Page: 2 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: SFUSD-JEFFERSON EARLY EDUCATION SCHOOL-PRESCHOOL
FACILITY NUMBER: 380504419
VISIT DATE: 01/05/2017
NARRATIVE
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Staff persons are current with First Aid/CPR certification expiring 07/31/2017. Director states Fire and Earthquake drills are done each month but were not logged. In regards to discipline of children, the director states that talking to the children and re-direction Positive behavior Intervention is used. LPA also went over all new regulations with the Licensee ( IMS, immunization, Toddlers, Civil penalties, smoking prohibition, Pesticides (DPR.ca.gov), Carbon monoxide detectors and Childhood Nutrition training. LPA observed Site Director posting the Notice of Site Visit. The report was reviewed with the director and no deficiencies were observed in this visit.
IMS AND PESTICIDES, 2016:
IMS:
IMS was discussed with the director this facility provides Incidental Medical Services - IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children's, personnel, and administrative records. File reviews of children and staff for IMS was conducted. The director was advised that information can be found on the website at ccld.ca.gov.
What is IMS?
  • Blood Glucose monitoring
  • Administration of: inhaled medication, Epi-pen and Epi pen Jr. or other epinephrine auto injectors, glucagon, gastronomy tube feeding and care, insulin injections, anti-seizure medications.
  • Carrying out medical orders when the child's physician has determined that a layperson can be trained and safely carry out the orders.
Prescription and non-prescription medications not associated with an IMS do not require an IMS Plan.
PESTICIDES:
Pesticide regulations were discussed with the director, In accordance with the Healthy Schools Act, California law requires that anyone using any pesticide must be trained every year in integrated pest management and the safe use of pesticides around children. The director was advised that a free one hour online course is available on the Department of Presticide Regulation's Web site: www.cdpr.ca.gov/schoolipm/training. If the director had questions she can email ccipmlist@cdpr.ca.gov. Director was also advised that bleach is considered to be a pesticide under the law.
LPA also went over all new regulations with the Licensee ( IMS (ADA.gov), immunization, Toddlers, Civil penalties, smoking prohibition, Pesticides (DPR.ca.gov), Carbon monoxide detectors and Childhood Nutrition training. LPA observed Site Director posting the Notice of Site Visit. The report was reviewed with the director and no deficiencies were observed in this visit.
SUPERVISOR'S NAME: Suzanne Roman-ClarkTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Tony NgTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2017
LIC809 (FAS) - (06/04)
Page: 3 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: SFUSD-JEFFERSON EARLY EDUCATION SCHOOL-PRESCHOOL
FACILITY NUMBER: 380504419
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/06/2017
Section Cited
101439(h)(4)
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Infant changing tables shall:
(4) While in use, be placed within arm's reach of a sink.
( Infant changing table did not have a dedicated hand sink within arms reach. and placed in Classroom 1's children's bathroom. )
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Remove infant changing table or place a sink within arms reach of the the table.
Type B
01/12/2017
Section Cited
101174(d)(2)
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(d) Disaster drills shall be conducted at least every six months.
(2) The drills shall be documented. This documentation shall be kept in the child care center for at least one year.
( Drills conducted but not recorded )
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After each drill the event must be logged per laws and regulations.
Type B
01/12/2017
Section Cited
101212(b)
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101212(b) Reporting Requirements. The name of the child care center director or fully qualified teacher(s) designated to act in the director’s absence shall be reported to the Department with in 10 days of a change.
( New director was not reported per laws and regulations.)
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Facility will have until 01/12/17 to provide new director information, LIC308, 500, 501, 503, 508, 610, 9108, 9182, transcripts or qualifications, CPR and first aid, one hour nutrition or equivalent, proof of completion of "Operations and record keeping" orientation.
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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: Suzanne Roman-ClarkTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Tony NgTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2017
LIC809 (FAS) - (06/04)
Page: 4 of 4