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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414002299
Report Date: 03/02/2022
Date Signed: 03/02/2022 11:56:55 AM

Document Has Been Signed on 03/02/2022 11:56 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:CITY OF PACIFICA-FAIRMONT STATE PRESCHOOLFACILITY NUMBER:
414002299
ADMINISTRATOR:LILLIAN PAULSENFACILITY TYPE:
850
ADDRESS:649 PARKVIEW CIRCLETELEPHONE:
(650) 738-7381
CITY:PACIFICASTATE: CAZIP CODE:
94044
CAPACITY: 30TOTAL ENROLLED CHILDREN: 15CENSUS: 15DATE:
03/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Debbie MahoneyTIME COMPLETED:
12:10 PM
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On March 2, 2022 at 08:25 AM, Licensing Program Analyst (LPA) Cowan met with teacher Debbie Mahoney, for a 1 Year Required Inspection. Purpose of the inspection was explained, and LPA was allowed access into facility. Site director Lillian Paulsen arrived at 8:57 AM to continue the inspection with LPA. Present this day, in the facility are director, 2 staff, and 15 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 06:00 PM.

With director, LPA inspected the day care rooms 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. The bathrooms is in working condition. All storage containers for solid waste have fitted lids. All food is stored properly to avoid contamination. Facility has a sufficient amount of sleeping matts available. Bottles and other items provided by the parents are labeled and stored appropriately. Food preparation area is free of litter. Food is stored adequately to prevent contamination. Play yard is free of hazards. The facility is located in a city park and uses its playground. The facility has exclusive access to the park between the hours of 10:30 AM to 12:00 PM and 3:00 PM - 4:30 PM, given by the city. There is a sufficient amount of bark in the play yard to help absorb the impact of falls. Staff bring children's labeled water bottles from the classroom to the playground areas when on the play yard.
Report continues on next page……….
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: April Cowan
LICENSING EVALUATOR SIGNATURE: DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/02/2022
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: CITY OF PACIFICA-FAIRMONT STATE PRESCHOOL
FACILITY NUMBER: 414002299
VISIT DATE: 03/02/2022
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LPA observed facility's sign in/out sheets. LPA observed that parents have signed children in using full signatures. 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 1/19/22 and is properly logged. At 8:50 AM, LPA reviewed the facility records. LPA reviewed 10 random children's files. Children's files are complete with all required Licensing documents. LPA reviewed 2 staff's files. One file is complete with required Licensing documents. At: 8:50 AM, LPA observed that staff Ref#1 did not have licensing documents on file. This staff member is associated to another City of Pacifica site where the file is kept per director. LPA also observed that staff was not associated to the facility. Technical violations are issued this day.

LPA discussed facility postings, staff files, and associations with site director. LPA discussed Covid-19 protocols with site director.


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

DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022
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: CITY OF PACIFICA-FAIRMONT STATE PRESCHOOL
FACILITY NUMBER: 414002299
VISIT DATE: 03/02/2022
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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.

>No deficiencies were cited today under CCR, Title 22, Division 12, Chapter 3.

Exit interview conducted and report was reviewed with the site director Lillian Paulsen

This report must be available in the facility for public review. Notice of site visit is to be posted. 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

The copy of this report is reviewed and provided to the director. Notice of site visit is posted and shall remain posted for next 30 days.

Copy of this report was reviewed and will be emailed to the director, Lillian Paulsen at PAULSENL@CI.PACIFICA.CA.US by the close of business on 3/2/22. Confirmation of receipt is required. Signed copy of this report will be stored in the facility file.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: April Cowan
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022
LIC809 (FAS) - (06/04)
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