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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410509300
Report Date: 05/26/2023
Date Signed: 05/26/2023 03:57:34 PM

Document Has Been Signed on 05/26/2023 03:57 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:PACIFICA NURSERY SCHOOLFACILITY NUMBER:
410509300
ADMINISTRATOR:JACKSON, CHRISTINAFACILITY TYPE:
850
ADDRESS:548 CARMEL AVENUETELEPHONE:
(650) 355-4465
CITY:PACIFICASTATE: CAZIP CODE:
94044
CAPACITY: 35TOTAL ENROLLED CHILDREN: 35CENSUS: 17DATE:
05/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Kathleen BurnsTIME COMPLETED:
03:25 PM
NARRATIVE
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On May 26, 2023 at 11:45 AM, Licensing Program Analyst (LPA) Cowan met with teacher Kathleen Burns, for a 1 Year Required Inspection. Purpose of the inspection was explained. Present, in the facility is teacher, 5 parents, and 17 children in care. The director is not present this day. Facility is operating within its capacity, and facility is in compliance with staff / child ratio on this day. Facility operates day care Monday to Friday from 8:45 AM to 12:45 PM.
With teacher, LPA inspected the day care room and play yard. LPA observed facility has working smoke detector, carbon monoxide detector, fully charged fire extinguisher, and working telephone on site. All cleaning solutions, poisons and other chemicals dangerous to the children are stored inaccessible to the children. Facility has age appropriate furniture. Facility floor is in good repair and free of any hazards. There are first aid supplies available in the classroom. All bathrooms are in working condition. All storage containers for solid waste have fitted lids. Play yard is free of hazards. There is a sufficient amount of bark to help absorb the impact of falls. There is water available on the yard as well as in the classroom.

LPA reviewed the facility's sign in / out. LPA observed full signatures of parents. At 12:30 PM, LPA observed that the facility has not tested their water for lead exceedance. At 12:35 PM, LPA observed that the facility has not conducted an emergency drill within the past 6 months. The above are potential risks to children in care, and Type B citations are issued for these deficiencies. Facility has license and all other required documents posted and visible for the public.
At 12:35 PM, LPA reviewed the facility records. LPA reviewed 5 random children's files. Children’s files are complete with all required Licensing documents. Later, at 1:10 PM Board President, Robin Oxley Marquardt arrived to continue the inspection with LPA. LPA reviewed 1 staff's files. At 1:27 PM, LPA observed that Staff member did not have Health Screening, Employee Rights, Current Mandated Reporter Training, and current CPR and First Aid Training on file. These are potential risks to children in care and Type B citations are issued for the above deficiencies.

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.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
Report continues on next page……….
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: April Cowan
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2023
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 5
Document Has Been Signed on 05/26/2023 03:57 PM - It Cannot Be Edited


Created By: April Cowan On 05/26/2023 at 02:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PACIFICA NURSERY SCHOOL
FACILITY NUMBER: 410509300

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101174(d)
Disaster and Mass Casualty Plan
(d) Disaster drills shall be conducted at least every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (record review), the licensee did not comply with the section cited above in that the facility's last logged drill is 2-8-22 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2023
Plan of Correction
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Board President agrees to have staff conduct a drill and email documentation to LPA by the above statesd date.
Type B
Section Cited
HSC
1597.16(a)(1)
Lead Testing
(1) A licensed child day care center, as defined in Section 1596.76, that is located in a building that was constructed before January 1, 2010, shall have its drinking water tested for lead contamination levels on or after January 1, 2020, but no later than January 1, 2023, and every five years after the date of the initial test.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (interview), the licensee did not comply with the section cited above in the facility has not yet tested water for lead which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/26/2023
Plan of Correction
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Board President agrees to have water tested by the above stated date and send Licensing Documents to LPA by the above stated date.
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:Garfield Leung
LICENSING EVALUATOR NAME:April Cowan
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/26/2023 03:57 PM - It Cannot Be Edited


Created By: April Cowan On 05/26/2023 at 02:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PACIFICA NURSERY SCHOOL
FACILITY NUMBER: 410509300

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (record review) the licensee did not comply with the section cited above in that 1 out of 1 teachers did not have a current Mandated Reporter Training on file. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2023
Plan of Correction
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Board President agrees to have staff take training and email to LPA by the above stated date. (Kathleen Burns)
Type B
Section Cited
CCR
101216(f)
Personnel Requirements
(f) At least one staff member who is trained in pediatric cardiopulmonary resuscitation and pediatric first aid pursuant to Health and Safety Code Section 1596.866 shall be present when children are at the child care center or offsite for center activities.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (record review), the licensee did not comply with the section cited above in that no staff present had CPR and First Aid on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2023
Plan of Correction
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Board President agrees to send LPA CPR and First aid for Kathleen Burns.
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:Garfield Leung
LICENSING EVALUATOR NAME:April Cowan
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/26/2023 03:57 PM - It Cannot Be Edited


Created By: April Cowan On 05/26/2023 at 02:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PACIFICA NURSERY SCHOOL
FACILITY NUMBER: 410509300

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(g)(1)
Personnel Requirements
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (record review), the licensee did not comply with the section cited above in 1 out of 1 staff did not have Health Screening on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/26/2023
Plan of Correction
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Board President agrees collect Health Screening from staff by the above stated date or send in proof of seperations from facility.
Type B
Section Cited
CCR
101216(l)(1)(B)
Personnel Requirements
(B) A copy of the signed LIC 9052 (11/94) shall be kept in the employee's personnel record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (record review), the licensee did not comply with the section cited above in 1 out of 1 staff did not have Employee Rights on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2023
Plan of Correction
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Board President agrees to collect document from staff and email to LPA.
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:Garfield Leung
LICENSING EVALUATOR NAME:April Cowan
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2023


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: PACIFICA NURSERY SCHOOL
FACILITY NUMBER: 410509300
VISIT DATE: 05/26/2023
NARRATIVE
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Director 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.

Director is aware that all staff is required to complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com. LPA observed the completion certificates on file. LPA encourages the director to frequently visit our website at www.ccld.ca.gov for licensing regulations and new updates.

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. For questions, email ccipmlist@cdpr.ca.gov.


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.

>See next page for deficiencies

Exit interview is conducted, and report was reviewed with site director. Director was advised any additional questions to call Office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website: www.cdss.ca.gov

>This report and rights to comment and appeal were discussed with site director. This report must be available in the facility for public review. Notice of site visit is to be posted and shall remain posted for next 30 days.

Due to difficulties with LPA's printer, this report is emailed to site director at christinajackson224@yahoo.com and rmarquardt@thepacificacoop.org with a request for reply demonstrating receipt.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: April Cowan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023
LIC809 (FAS) - (06/04)
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