Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384002299
Report Date: 03/27/2017
Date Signed: 03/27/2017 03:44:09 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:C5 CHILDREN'S SCHOOL-SFPUC (PS)FACILITY NUMBER:
384002299
ADMINISTRATOR:WISEMAN, JOSEPHFACILITY TYPE:
850
ADDRESS:525 GOLDEN GATE AVENUETELEPHONE:
(415) 626-4880
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94102
CAPACITY:45CENSUS: 20DATE:
03/27/2017
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Roxanna ResumaTIME COMPLETED:
03:45 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
LPA Ng made a random annual inspection visit to the facility at issue. LPA met with Roxanne Resuma with 4 staff and 20 infants, all staff were fingerprinted and cleared. Facility is a preschool program center. There are no known guns or weapons within the facility. The room identification has been changed from alphabets to numbers and names. Rooms 174, 175, and 180 are used for the preschool program. In the classroom Furniture and equipment are age appropriate. There is adequate heating, lighting and ventilation. Water is served via staff, there is sufficient storage available for the children's belongings and sufficient space for the group size being served. All diaper changing stations met regulatory standards. There are sufficient cots to meet the needs of the capacity. In the toileting areas toilets flush, faucets work and are sensor operated. 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 tested at 73.9 degrees F. There is a separate staff bathroom. In regards to food service, The parents would order through a caterer to provide Lunch, and 2 snacks to the children. The food is prepared off site and catered by Chefables. There is a food prep kitchen area the, food items present were inspected & no deficiencies were found, all kitchen equipment were working within guidelines of the law. Menu is posted both in the kitchen, classrooms and online. In the inspection of the outdoor area, the outdoor area there is a play structure, all of the metal poles have been wrapped with cushioning. There are also a combination of activities and items that children use to develop gross motor skills. The items were observed to be used at times are questionable as to their usage, for example using plastic milk cartons as a gross motor activity, LPA has advised against use of items not meant for its purpose. The flooring material is of soft rubber matting on the outside. The gross motor space is a part of the two programs common usage space to meet outdoor requirements. Currently the gross motor space has been transformed into the Seashore classroom, this area must be reconfigured back to a gross motor space as there is not enough outside space to meet outdoor space capacity requirements, half of space "C" remain a multi-purpose room but not a gross motor space. In regards to health related services, the Site Director states medications may be dispensed if a parent provides note and also is a prescription no over the counters. Medication will be stored in the staff work area in the middle of the the room in the upper cabinets, refrigerated medications will be placed in a lock box in the refrigerator. There are children currently on medications, children are greeted and checked for illness. There are first aid supplies and thermometer is available.
SUPERVISOR'S NAME: Suzanne Roman-ClarkTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Tony NgTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2017
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 3


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: C5 CHILDREN'S SCHOOL-SFPUC (PS)
FACILITY NUMBER: 384002299
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/10/2017
Section Cited
101212(c)(1)
1
2
3
4
5
6
7
The licensee shall notify the Department in writing of his/her intent prior to making any structural changes that reduce the total amount of indoor or outdoor activity space. Such structural changes shall include, but not be limited to, room additions.
( Gross motor space turned into Seashore classroom.)
1
2
3
4
5
6
7
Facility must revert facility back to its original conditions or apply for changes by due date.
Type B
04/10/2017
Section Cited
HS1596.954
1
2
3
4
5
6
7
No information on current sensors act as both smoke and carbon monoxide detectors. Therefore it will be considered that facility does not have carbon monoxide detectors currently.
1
2
3
4
5
6
7
Install carbon monoxide detectors by due date.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 03/27/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2017
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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: C5 CHILDREN'S SCHOOL-SFPUC (PS)
FACILITY NUMBER: 384002299
VISIT DATE: 03/27/2017
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
26
27
28
29
30
31
32
There are Earthquake emergency items available at this visit. Isolation is provided in the office with the use of the staff bathroom if needed. In regards to the discipline policy used in the facility, the Director states that they talk with children stressing a positive guidance approach to correct issues by understanding and not reprimanding.
RECORDS: Staff and children's files were reviewed. Facility has posted the required forms (i.e. License, menus, waivers, Notification of Parent's Rights, Notification of Personal Rights, Car Seat Law, and Emergency Disaster Plan). First Aid/CPR certification is current to August 2017.
FACILITY IS PROVIDING IMS: 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 Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Section 101173 and 101226. 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. Facility will submit a written plan by the end of April 2017. Facility was also informed that as of September 1, 2016, a person may not be employed or volunteer at a child care facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662. All staff have updated required immunization record in file. Facility has one child using IMS, file was reviewed.

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 Pesticide 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), 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: 03/27/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2017
LIC809 (FAS) - (06/04)
Page: 3 of 3