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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004089
Report Date: 11/16/2022
Date Signed: 11/16/2022 11:43:02 AM

Document Has Been Signed on 11/16/2022 11:43 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:EXCELSIOR FAMILY CONNECTIONSFACILITY NUMBER:
384004089
ADMINISTRATOR:SIHAPANYA, YENSINGFACILITY TYPE:
850
ADDRESS:5016 MISSION STREETTELEPHONE:
(415) 333-3845
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94112
CAPACITY: 20TOTAL ENROLLED CHILDREN: 20CENSUS: 11DATE:
11/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Eleazar MartinezTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Yee conducted a Required - 1 Year inspection today. The purpose of the inspection was explained. Present at the facility are the site manager, Eleazar Martinez, 2 staff members, and 11 children. Teacher-to-child ratios were met during today's visit. Days and hours of operation: Monday - Friday, 9:00 am - 12:00 pm. The facility has fully charged fire extinguishers that meet the minimum requirements, smoke detectors, and a carbon monoxide detector. The outside yard is adjacent to the classroom. The outdoor yard waiver is posted it.

LPA and Site manager, Eleazar Martinez toured and inspected the Center for Health and Safety Hazards. Daycare areas: one large room, and an outside yard. LPA observed outdoor equipment is in good condition, free from loose, sharp, or pointed parts. There are no pools, spas, or other bodies of water on the premises. All cleaning supplies and other potentially harmful items are made inaccessible to the children. Furniture and equipment are in good condition. Isolation for a sick child is available. The facility provides snacks. Drinking water is provided indoor and outdoor. The last Emergency Drill was conducted on 10-24-2022 and properly logged.

During the inspection, LPA reviewed 2 staff’ members' files and was in order. At least one staff have current Pediatric First Aid and CPR on file (6-17-2023). Children's files were reviewed and in order. The facility has posted all the required licensing forms in a prominently visible location.


LPA discussed Child Abuse Mandated Training AB1207 with the Site manager. 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. All staff members have current AB1207 certificates.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jennifer Yee
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2022
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: EXCELSIOR FAMILY CONNECTIONS
FACILITY NUMBER: 384004089
VISIT DATE: 11/16/2022
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Pesticide regulations were discussed with the Site manager. 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.

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 Sections 101173 and 101226. 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)/ (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 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.

LPA advised the facility to do a lead water testing if the building was built prior to 2010. The facility may find information under PIN 21021-CCP and 22-06-CCP.

Annual fees is due on 12-02-2022. A copy of an invoice was left with the facility. During the visit, LPA obtained current LIC610, LIC308.

An Exit Interview was conducted with Site director. No deficiencies were issued today under Title 22 Division 12 of the California Code of Regulations. For updates on Licensing information, go to CCL website: www.ccld.ca.gov. For Provider Information Notice: ccld.ca.gov/PG5098.htm
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jennifer Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022
LIC809 (FAS) - (06/04)
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