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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414002299
Report Date: 01/27/2023
Date Signed: 01/27/2023 12:04:44 PM

Document Has Been Signed on 01/27/2023 12:04 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
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:
01/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:29 AM
MET WITH:Debbie Mahoney and Lillian PaulsenTIME COMPLETED:
12:20 PM
NARRATIVE
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On January 27, 2023 at 8:29 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 granted entry into facility. There were two teachers present in the facility with three children. At 9:06 AM, site director, Lillian Paulsen, arrived and continued inspection with LPA. Now, present in the facility is director, 3 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 to 6:00 PM. When LPA arrived, children were arriving and participating in free play. Children soon transition into a Chinese New Year activity using motor skills and learning numbers and letter.

With director, 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. The bathroom toilets and sinks are working condition. All storage containers for solid waste have fitted lids. Facility has a sufficient amount of sleeping matts available. Food preparation area is free of litter. Food is stored adequately to prevent contamination. 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 observed facility's sing in/out sheets. LPA observed that parents are using full signatures. Facility has license and all other required documents are 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 10/13/22 and is properly logged. At 9:35 AM, LPA reviewed the facility records. LPA reviewed 3 random staff's files. All staff have criminal record clearance of file and Acknowledgement to Report Child Abuse. Mandated Reporter Trainings are current. LPA reviewed 6 random children's files. At 10:32 AM, LPA observed that two children did not have Physicians Report on file. This is a potential risk to children in care. A Type B citation is issued for this deficiency. 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: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2023
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 01/27/2023 12:04 PM - It Cannot Be Edited


Created By: April Cowan On 01/27/2023 at 11:09 AM
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-FAIRMONT STATE PRESCHOOL
FACILITY NUMBER: 414002299

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101220(a)
Child's Medical Assessments
(a) Prior to, or within 30 calendar days following the enrollment of a child, the licensee shall obtain a written medical assessment of the child. This medical assessment enables the licensee to assess whether the center can provide necessary health-related services to the child.

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 2 out of 6 children did not have Physicians Reports on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2023
Plan of Correction
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Director agree to collect LIC 701 Physicians Report for Diana and Sophie Chan and email to LPA by the above 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: 01/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2023


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
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: 01/27/2023
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LPA discussed Covid-19 Protocols with site director. Facility files and supervision of children were also discussed.

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, Lillian Paulsen. 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 Licensee. 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: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023
LIC809 (FAS) - (06/04)
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