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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414001721
Report Date: 06/21/2024
Date Signed: 06/21/2024 04:36:02 PM

Document Has Been Signed on 06/21/2024 04:36 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 SCHOOL-AGE CC PRGMFACILITY NUMBER:
414001721
ADMINISTRATOR/
DIRECTOR:
HOWARD, RONDELLFACILITY TYPE:
840
ADDRESS:100 TERMINAL AVE, BUILDING ATELEPHONE:
(650) 330-2245
CITY:MENLO PARKSTATE: CAZIP CODE:
94025
CAPACITY: 67TOTAL ENROLLED CHILDREN: 62CENSUS: 27DATE:
06/21/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Natalya JonesTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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On June 21,2024, Licensing Program Analyst (LPA) Kassandra Medrano conducted a random annual licensing inspection today. LPA met with Natalya Jones, the purpose of the visit was explained. The facility is located on the campus of Belle Haven Community Center. Analyst inspected the facility building and grounds, conducted an evaluation of the physical plant, and reviewed children, staff and facility records. A review of staff records during today’s visit indicates that all staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. But it was found that three staff were not associated to the facility. Facility representative 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. The following was observed today: Current rooms used for care are: Rooms 108 and 143. The following items were reviewed as part of today's visit: Care and Supervision of the Children, Child Discipline Procedures, Emergency Evacuation Procedures. Smoke and carbon monoxide detectors present and in working order, Medication Policies, Isolation of Sick Children, Food Service, Transportation, Parents Rights, and Reporting Requirements. Bathrooms for school age children are located within classroom 108 and adjacent to room 143. Supervision of school age children coming and going from the bathrooms and at the bathrooms is achieved by: Direct supervision, the children have exclusive use of restrooms when program operates. Children are signed in to the facility by Program staff and out of the facility by legal guardians. Posting requirements for site visits were discussed as well as AB 633 requirements. Current forms and Title 22 Regulations can be obtained through the internet at www.ccld.ca.gov. Director was reminded 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 reviewed with facility representative the LIC 311A, Records To Be Maintained At The Facility, for child’s records, personnel records, administrative records, and documents to be posted.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Kassandra Medrano
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2024
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 SCHOOL-AGE CC PRGM
FACILITY NUMBER: 414001721
VISIT DATE: 06/21/2024
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Director was advised of the required annual pesticides training. For More information about changes to the Healthy Schools Act, templates, or articles, you can inspect the DPR website at:
https://apps.cdpr.ca.gov/schoolipm/childcare/training/main.cfm. 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. For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1- CCP). LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP. Due to the new build of the facility, facility is exempt from lead testing. Director was informed about the Provider Information Notices (PINs) on CCLD website. Director was reminded of Mandated Reporter Training available on CCLD website. Training must be renewed every two years.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 PIN 22-02-CCP. 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-carecenters/. Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. facility representative 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.To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication. 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.

Notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the facility representative, Natalya.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Kassandra Medrano
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/21/2024 04:36 PM - It Cannot Be Edited


Created By: Kassandra Medrano On 06/21/2024 at 04:10 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 SCHOOL-AGE CC PRGM

FACILITY NUMBER: 414001721

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 06/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(i)(2)


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 3 staff were not associated to facility which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/24/2024
Plan of Correction
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Director to associate staff.
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:Ali Zebila
LICENSING EVALUATOR NAME:Kassandra Medrano
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024


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