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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380500371
Report Date: 08/24/2023
Date Signed: 08/24/2023 12:00:38 PM

Document Has Been Signed on 08/24/2023 12:00 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
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:LAKESIDE PRESBYTERIAN CHURCH NURSERY SCHOOLFACILITY NUMBER:
380500371
ADMINISTRATOR:MICHELLE ADELSHEIMFACILITY TYPE:
850
ADDRESS:201 EUCALYPTUS DRIVETELEPHONE:
(415) 564-5044
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94132
CAPACITY: 75TOTAL ENROLLED CHILDREN: 75CENSUS: 70DATE:
08/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Michelle AdelsheimTIME COMPLETED:
12:30 PM
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On August 24, 2023., Licensing Program Analyst (LPA) Van met with Director Michelle Adelsheim for an unannounced annual random inspection. The purpose of the inspection was explained to the Director. This is a preschool program. Today, 19 staff supervised 70 preschool children. The facility complies with the staff-children ratios today. All staff members have criminal record clearances on file. The days and operations hours are Monday - Friday from 7:30 a.m. to 6:00 p.m.

LPA toured and inspected the physical plant for any health and safety hazards. The facility has an electronic sign-in/out. Per the Director, each family is provided with a log-in code. The facility is in good repair and has proper temperature and ventilation. All classrooms have age-appropriate toys and learning materials. The furniture appears steady and in good repair. The facility has a centralized smoke alarm, carbon monoxide detector, fully charged fire extinguishers, and working telephones. LPA observed that each child has their cubbies available with their name labeled in each classroom. All emergency supplies are stored in locked storage. Medications are appropriately labeled and kept out of reach of children. LPA reminded the Director that all medications should be in their original, unaltered box. First aid supplies are fully stocked and available for children's use. All cleaning solutions, poisons, and other dangerous chemicals are stored in an area inaccessible to children. Sleeping cots are appropriately stored. All children's toilets and handwashing sinks are in good working condition with proper sanitation. There is a separate bathroom for staff usage on the premises. LPA observed no bodies of water on the premises.
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SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
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
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: LAKESIDE PRESBYTERIAN CHURCH NURSERY SCHOOL
FACILITY NUMBER: 380500371
VISIT DATE: 08/24/2023
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During today’s inspection, the outdoor playground was not inspected. The Director informed LPA that the playground was closed off while the building got its new paint coat. LPA reminded the Director to contact Desk Duty and complete an incident report.

The facility had posted the required forms. (i.e., License, Notification of Parent's Rights, Personal Rights, Car Seat Law, Emergency Disaster Plan, and Daily activities). The facility has water bottles readily available for children indoors and outdoors. All storage containers for solid waste within the Center have a proper tight-fitting cover.

Random children's records and personnel records were reviewed during the inspection. Records review showed the facility has records of each child's authorized representative's names, addresses, and telephone numbers. In addition, each child's immunization record, medical assessment, and admission agreement can be located in each child's file. Staff records indicate that all staff or other individuals who require caregiver background checks have received criminal records and child abuse index clearances or exemptions. All staff members have a record of valid CPR and maintain proper immunization records. LPA reviewed the Director's and staff's educational qualifications, and all staff had the required ECE units. The Director stated that the Center conducts fire and earthquake drills monthly; the last drills were conducted on May 31, 2023.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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.
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SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: LAKESIDE PRESBYTERIAN CHURCH NURSERY SCHOOL
FACILITY NUMBER: 380500371
VISIT DATE: 08/24/2023
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The Director was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test.

During the inspection, the Director provided LPA with the water lead testing results, including the External Water Sampler self-certification form (LIC 9275) and Child Care Center Sampling Checklist Form (LIC 9276). However, it was found that a Certified Sampler did not complete the test. LPA informed the Director that a retest is required and must be from a Certified Sampler.

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 are available at: https://www.ada.gov/resources/child-care-centers/.

The Director was informed of the MyChildCarePlan.org website; 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
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SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: LAKESIDE PRESBYTERIAN CHURCH NURSERY SCHOOL
FACILITY NUMBER: 380500371
VISIT DATE: 08/24/2023
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LPA discussed Child Abuse Mandated Training AB1207 with the Director. As of January 1, 2018 all staff will be required to complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com.

Pesticide regulations were discussed with the Site 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. For questions, email ccipmlist@cdpr.ca.gov.

An exit interview was conducted and reviewed with the Director. A copy of this report was provided to the Site Director, whose signature on this form confirms receipt of these reports. Notice to be remain posted for 30 days. For updates on Licensing information, go to CCL website: www.ccld.ca.gov. For Provider Information Notice: ccld.ca.gov/PG5098.htm
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
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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