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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004603
Report Date: 09/14/2021
Date Signed: 09/14/2021 02:20:28 PM

Document Has Been Signed on 09/14/2021 02:20 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:TRINITY LUTHERAN PRESCHOOLFACILITY NUMBER:
414004603
ADMINISTRATOR:CORPUZ, ANGELINAFACILITY TYPE:
850
ADDRESS:1248 BALBOA AVENUETELEPHONE:
(650) 580-2349
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 26TOTAL ENROLLED CHILDREN: 0CENSUS: 16DATE:
09/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Jam EyvazovTIME COMPLETED:
01:45 PM
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On Sept 14, 2021, Licensing Program Analyst (LPA) Van made an unannounced Annual Random inspection and met with new Site Director Jam Eyvazov. (Director stated, all paperwork/qualifications for Director will be submitted to Licensing this week). The facility is operating in the Trinity Lutheran Church's ground. The purpose of the inspection was explained and granted entry to the facility by the staff. Three staff were supervising 16 children at the Center. The Hours of operation are Monday to Friday, 8:00 am to 5:30 pm.

LPA and Director inspected the facility for health and safety hazards. LPA observed no bodies of water on the premises. Per Director, there are no firearms or weapons in the Center. The facility has multiple carbon monoxide detectors, a centralized smoke alarm, a fully charged fire extinguisher, and a working telephone. Classrooms are in good condition with proper temperature and ventilation and are free of any hazards. All classrooms have age-appropriate toys, furniture, and equipment. Furniture appears steady and in good repair. All toilets, hand washing facilities are in good working condition with proper sanitation in place. All cleaning solutions, poisons, and other dangerous chemicals are stored in the Church's garage, inaccessible to children in care. Outdoor play structures are age-appropriate and in good condition, with sufficient cushioning underneath.

LPA observed that the facility had posted the required forms. (i.e., License, menus, waivers, Notification of Parent's Rights, Notification of Personal Rights, Car Seat Law, and Emergency Disaster Plan). Per Site Director, the Center is providing lunch, morning, and afternoon snacks. Drinking water is available for children indoors and outdoors. The kitchen area is clean and free of any toxins or contamination. All storage containers for solid waste within the Center have a proper tight-fitting cover. Continued on the next page...
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2021
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: TRINITY LUTHERAN PRESCHOOL
FACILITY NUMBER: 414004603
VISIT DATE: 09/14/2021
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During the inspection, random children's records and personnel records were reviewed. LPA observed that the facility has an electronic sign-in/out record using the Bright-Wheel's app. According to Site Director, parents or guardians are assigned a specific Pin to access the sign/in and out, and the parent's full signature is required. LPA observed facility records each child's authorized representative's names, addresses, and telephone numbers. In addition, the immunization record of each child can be located in each child's file. Staff records review showed multiple staff members have a record of valid CPR in file and immunization on their respective file. LPA reviewed the educational qualification of all the teachers. The site Director stated that the Center is conducting fire and earthquakes every 20th of the calendar month.

Incidental Medical Services (IMS) policy was discussed. For IMS information, see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. 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

The 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.

The Director was informed about Mandated Reporter training available on the CCLD website. In addition to AB1207 training required to complete every two years by the Licensee and all staff hired, a one-time General Training is also required. Training can be taken online at www.mandaterreporterca.com. Also, the Director was reminded of Pesticides training. Information on the DPR website at: www.cdpr.ca.gov/shoolipm/childcare continued on the next page...
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: TRINITY LUTHERAN PRESCHOOL
FACILITY NUMBER: 414004603
VISIT DATE: 09/14/2021
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LPA encouraged the Director to frequently visit CCLD website at www.ccld.ca.gov for licensing regulations and new updates. Director can also email at childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list for the updates.

No deficiencies are cited today. Exit interview conducted, and the report was reviewed with the Director, Jam Eyvazov. Today's report, 9/14/2021, and notice of site visit will be sent to the Director by email by the close of business on 9/14/21. Confirmation of receipt is required. LPA informed the Director that the notice of site visit must be posted for 30 days.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021
LIC809 (FAS) - (06/04)
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