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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210105114
Report Date: 06/15/2022
Date Signed: 06/15/2022 01:43:32 PM

Document Has Been Signed on 06/15/2022 01:43 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:SAN ANSELMO CO-OPERATIVE NURSERY SCHOOLFACILITY NUMBER:
210105114
ADMINISTRATOR:NOWLEN, REBECCAFACILITY TYPE:
850
ADDRESS:24 MYRTLE LANETELEPHONE:
(415) 454-5308
CITY:SAN ANSELMOSTATE: CAZIP CODE:
94960
CAPACITY: 28TOTAL ENROLLED CHILDREN: 24CENSUS: 0DATE:
06/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:28 PM
MET WITH:Rebecca NowlenTIME COMPLETED:
01:38 PM
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On June 15th,2022 at 12:28pm, Licensing Program Analyst (LPA) Kassandra Medrano conducted an annual required inspection. Analyst toured the facility building and grounds, conducted an evaluation of the physical plant, and reviewed children, staff and facility records. A review of staff records during today’s visit indicates that all staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions facility representative was reminded that all adults 18 and over, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated. Days and hours of operation are:9am-4pm, Monday-Thursday, and Fridays 9am-12pm.The following was observed today: Facility is currently closed, to prepare for summer session. There were no children present during visit. Current facility director is Rebecca Nowlen. The following items were reviewed as part of today's visit: Care and Supervision of the Children, Child Discipline Procedures, Emergency Evacuation Procedures (smoke and carbon monoxide detectors present and in working order), Medication Policies, Isolation of Sick Children, Napping Requirements, Food Service, Transportation, Parents Rights, and Reporting Requirements. Posting requirements for site visits were also discussed as well as AB 633 requirements. Current forms and Title 22 Regulations can be obtained through the internet at www.ccld.ca.gov. Staff immunization are on file. Director was reminded 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. Influenza Declarations were also reviewed.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Kassandra Medrano
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2022
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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: SAN ANSELMO CO-OPERATIVE NURSERY SCHOOL
FACILITY NUMBER: 210105114
VISIT DATE: 06/15/2022
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Director was advised of Pesticides training. For More information about changes to the Healthy Schools Act, templates, articles, and required training you can inspect the DPR website at: https://apps.cdpr.ca.gov/schoolipm/childcare/training/main.cfm. Director was informed about the Provider Information Notices (PINs) on CCLD website. Director was reminded of Mandated Reporter Training available on CCLD website. Training must be renewed every two years. LPA discussed the safe sleep regulations with facility representative and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed facility representative of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment. Facility is clean and in good repair. To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process. Exit interview conducted and report was reviewed with the facility representative, Rebecca.

A notice of site visit was given and must remain posted for 30 days.

SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Kassandra Medrano
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2022
LIC809 (FAS) - (06/04)
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