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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414001146
Report Date: 01/12/2024
Date Signed: 01/12/2024 01:00:25 PM

Document Has Been Signed on 01/12/2024 01:00 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 CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:CITY OF MENLO PARK-BELLE HAVEN CHILD DEV CENTERFACILITY NUMBER:
414001146
ADMINISTRATOR:STORMS, KIRAFACILITY TYPE:
850
ADDRESS:410 IVY DRIVETELEPHONE:
(650) 330-2270
CITY:MENLO PARKSTATE: CAZIP CODE:
94025
CAPACITY: 96TOTAL ENROLLED CHILDREN: 61CENSUS: 55DATE:
01/12/2024
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Director, Kira StormsTIME COMPLETED:
01:20 PM
NARRATIVE
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On January 12th, 2024 at approximately 11AM, Licensing Program Analyst (LPA) Tapia-Mandujano conducted an unannounced, case management inspection for the Action Level Exceedance (ALE) of Lead in Child Care Center's water as well as a Case Management for an Unusual Incident Report that was submitted to the department.

LPA met with Director, Kira Storms. LPA explained the purpose of the visit to Director. Present in the facility are Director with 11 staff supervising 55 children. All adults working in the facility are fingerprint cleared and associated to the facility. Facility is currently operating within teacher to child ratio on this date.

LPA discussed the new Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018 requires the Lead Testing of water in the Child Care Center with the Director during the inspection. All Child Care Centers that are located in buildings constructed before January 1, 2010, must have their water tested and post the results by January 1, 2023, and every 5 years after the date of the first testing.

Facility tested in May of 2022, however not all the faucets that are used for drinking and/or prepping were tested. Director understands that all faucets that will be used for drinking and/or food prepping need to be tested.

The facility was not initially cited for the ALE during annual visit on 12/05/2023 due to clarification on conflicting information the facility received. Due to updated guidance regarding the Written Directives for Lead Testing detailed in PIN 21-21.1-CCP, the facility must be cited for not testing all faucets required. Citation was given today and POC was developed. Please refer to LIC 809D for more details.

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SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2024
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 CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: CITY OF MENLO PARK-BELLE HAVEN CHILD DEV CENTER
FACILITY NUMBER: 414001146
VISIT DATE: 01/12/2024
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LPA also did a Case management for an incident that the facility self reported. The incident occurred on December 12th, 2023. The incident involved lack of supervision that resulted in a child walking out with another family during pick up. Per conversation with Director, child involved walked out as the staff member was verifying pick up information that involved another child. Per Director, during the time the staff member looked away, the child had left the room and was walking next to another family who proceeded to exit the daycare premises. Per Director, the child did make it out of the preschool but was stopped right at the main entrance of the building. Per Director, this incident happened in approximately one minutes. Per Director, there were eyes on the child at all times during the incident, however the child did exit daycare premises.

During today's inspection, LPA inspected the area where the incident took place. Per conversation with Director, immediate action was taken and a conversation with all staff was incorporated during their staff meeting on that day, as well as the staff involved had a one on one training with Director. Due to a potential health and safety risks for lack of supervision, a Type B deficiency has been issued. Please see LIC 809D for more details. Deficiency will be cleared during today's inspection.

This report must be available in the facility for public review. Notice of site visit shall be posted for 30 days from today's visit. An exit interview was conducted with Director, Kira Storms.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024
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Document Has Been Signed on 01/12/2024 01:00 PM - It Cannot Be Edited


Created By: Leslit Tapia-Mandujano On 01/12/2024 at 12:18 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: CITY OF MENLO PARK-BELLE HAVEN CHILD DEV CENTER

FACILITY NUMBER: 414001146

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 01/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/12/2024
Section Cited

101701(a)(1)

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101701(a)(1): California Lead Action Level at Child Care Centers: "All faucets, fountains, coolers, bubblers, bottle filling stations, and filtered water dispensers located on the exterior and interior of buildings... shall be evaluated to assure that all applicable water outlets are tested"

This requirement is not met by:
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Facility will test all the faucets that they use for drinking and/or prepping food by a certified water tester and submit results to the department.
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Based on results received from the certified water samplers, not all the facutes that are used for drinking and/or food prepping were tested which poses a potential health, safety, or personal rights risk to persons in care.
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Type B
01/12/2024
Section Cited
CCR101229(a)(1)

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101229: Responsibility for Providing Care and Supervision: (a) "The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time... Supervision shall include visual observation."

This requirement is not me by:
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Facility will conduct a training with all staff and provide additional training to staff involved.

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Based on interviews and record review conducted, the facility did not comply with the section cited above as facility self reported that there was a child whom left the daycare premises, which poses a potential health, safety or personal rights risk to persons in care.
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On 12/12/23, Director incorportated a conversation at the staff meeting that they were holding to talk about the incident and provide additional reminders and training for staff, as well as did a one on one with the staff involved.

Deficiency will be cleared.
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:Marie Rodriguez
LICENSING EVALUATOR NAME:Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2024


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