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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414001585
Report Date: 04/13/2023
Date Signed: 04/13/2023 04:17:24 PM

Document Has Been Signed on 04/13/2023 04:17 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:CITY OF PACIFICA-CABRILLO CHILDREN'S CTR.-SCH AGEFACILITY NUMBER:
414001585
ADMINISTRATOR:YAKUBOVICH, MARINAFACILITY TYPE:
840
ADDRESS:601 CRESPI DR., PORT. 1, 2,&3TELEPHONE:
(650) 738-9251
CITY:PACIFICASTATE: CAZIP CODE:
94044
CAPACITY: 108TOTAL ENROLLED CHILDREN: 77CENSUS: 57DATE:
04/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Marina YakubovichTIME COMPLETED:
04:31 PM
NARRATIVE
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On April 13, 2023 at 1:30 PM, Licensing Program Analyst (LPA) Cowan met with site director, Marina Yakubovich, for a 1 Year Required Inspection. Purpose of the inspection was explained. Present, in the facility is director, 6 staff, and 57 children in care. 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 07:00 AM to 6:00 PM. Facility operates from three portables: P1, P2, and P3. The facility is operating on the grounds of Cabrillo Elementary School.

With director, LPA inspected the day care room and play yard. LPA observed facility has working smoke detectors, carbon monoxide detectors, fully charged fire extinguishers, 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 along with books and toys.
There are first aid supplies available in the classrooms. All bathrooms are in working condition. All storage containers for solid waste have fitted lids. Food preparation area is free of litter. Food is stored adequately to prevent contamination. Play yard is free of hazards. There is water available on the yard as well as in the classroom.
LPA observed that facility flooring in two classrooms are in disrepair. LPA discussed facility floors with site director who states that the storms have damaged the facility's floors, and she has already put in an order with Park, Beaches and Recreation Department to have floors replaced.

LPA observed that facility's sign in / out. Facility has license and all other required documents posted and visible for the public. There are menus posted at least one week in advance and are visible to the child's authorized representative. Facility’s last emergency drill was conducted 10/21/22 and is properly logged. At 2:22 PM, LPA reviewed the facility records. LPA reviewed 5 random staff's files. At 2:40 PM, LPA observed that a staff member did not have immunizations nor Health Screening with TB on file. At 2:42, LPA observed that a staff member did not have a current Mandated Reporter Training on file. These are potential risk for children in care and Type B citations are issued for these deficiencies. LPA reviewed 5 random children's files. Children’s files are complete with all required Licensing documents. Per director, all contact information of file is current.
Report continues on next page……….
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: April Cowan
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2023
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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Document Has Been Signed on 04/13/2023 04:17 PM - It Cannot Be Edited


Created By: April Cowan On 04/13/2023 at 03:09 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: CITY OF PACIFICA-CABRILLO CHILDREN'S CTR.-SCH AGE
FACILITY NUMBER: 414001585

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

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 5 staff did not have immunizations on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2023
Plan of Correction
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Director agrees to have staff bring immunizations for Lanea Tolbert and email to LPA by the above stated date.
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 1 out of 5 staff 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: 04/21/2023
Plan of Correction
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Director agrees to have staff bring in a current Mandated Reporter Training Certificate for Pablo Pena and email 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: 04/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2023


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 04/13/2023 04:17 PM - It Cannot Be Edited


Created By: April Cowan On 04/13/2023 at 03:09 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: CITY OF PACIFICA-CABRILLO CHILDREN'S CTR.-SCH AGE
FACILITY NUMBER: 414001585

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2023

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 that 1 out of 5 staff did not have a Health Screening with TB on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2023
Plan of Correction
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Director agrees to have staff bring in Health Screening with TB for Lanea Tolbert and email to LPA by the above stated date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 04/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2023


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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: CITY OF PACIFICA-CABRILLO CHILDREN'S CTR.-SCH AGE
FACILITY NUMBER: 414001585
VISIT DATE: 04/13/2023
NARRATIVE
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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
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.

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 Marina Yakubovich. 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.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: April Cowan
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023
LIC809 (FAS) - (06/04)
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