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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004787
Report Date: 06/09/2021
Date Signed: 06/09/2021 05:00:22 PM

Document Has Been Signed on 06/09/2021 05:00 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:UMC PRESCHOOL-BURLINGAMEFACILITY NUMBER:
414004787
ADMINISTRATOR:ARLETTE E. & VIKKI G.FACILITY TYPE:
850
ADDRESS:1443 HOWARD AVENUETELEPHONE:
(650) 347-6432
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 60TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
06/09/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Victoria Gomez & Arlette ErdozaincyTIME COMPLETED:
01:30 PM
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 Licensing Program Analyst (LPA) Glenn Schnell met with Applicants Victoria Gomez & Arlette Erdozaincy today for a pre-licensing inspection. This application is a change of ownership. The location of the program is on the property of United Methodist Church. The program will operate as a parent cooperative program and will utilize parent volunteers. The applicants will be leasing space from the Church. This inspection included a technical assistance inspection for COVID-19 guidance and support. The applicants are requesting 60 children (ages 2 years to entry into first grade). The facility will operate Monday - Friday; 8:00 AM to 2:00 PM. The designated director/site supervisors for the facility is are Arlette & Victoria. The facility was inspected today, indoor and outdoor, for health and safety hazards and measured to calculate capacity.

Indoor: There are five classrooms that will be used for the program and the following square footage was calculated for each room: Room 1 (Toddler/2): 834.95 sq ft. , Room 2 (Pre-Kindergarten/mixed age 2.5-5 years) 896.224 sq ft., Room 2A (Pre-Kindergarten/mixed age 2.5-5 years): 636 sq ft., Room 3 (3 and 4 year old): 611.868 sq ft., Room 3A (3 and 4 year old): 564.062. Total useable indoor square footage is 3543.104 sq ft divided by 35 sq ft equals 101 children. Room 1 has a small kitchen with a refrigerator, microwave and a sink for food prep and adult use. There is also a changing table in room 1 and one sink and toilet for children. Room 2 has a food prep area, refrigerator, microwave, table top convection oven, there is an adult sink in the classroom for food prep and two children sinks. Room 2A has one child sink. Room 3A has a small food prep area, one child sink and one adult sink for food prep. Report continues on the next page.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Glenn A Schnell
LICENSING EVALUATOR SIGNATURE: DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2021
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: UMC PRESCHOOL-BURLINGAME
FACILITY NUMBER: 414004787
VISIT DATE: 06/09/2021
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There is also a children's bathroom located outside of classroom 2 in the hallway with 2 sinks and 2 toilets. There is a bathroom for children with one sink and one toilet also located on the outdoor playground next to the staff bathroom.
The indoor space for children is observed today to be clean and all furnishing, toys and equipment observed to be safe and in good condition. There is storage space for children's personal belongings in each classroom. Since this is a half day program, there are no naps offered to children. Children will be signed in and out by authorized representatives using an electronic sign in/out program. The indoor space is equipped with a fire extinguisher, smoke and carbon monoxide detectors, garbage cans with tight-fitting lids, fully furnished first aid kit and emergency supplies. The facility is adequately ventilated and free of insects and bugs. The program normally provides one snack daily, but due to the COVID-19 pandemic, for the 2021-2022 school year parents will provide the snack. Only disposable products will be used for food service since the facility is not set up to provide adequate sanitization of dishes and utensils.

Snack foods will be stored in the refrigerators or cabinets in classrooms separately from any cleaning products, medications or other hazards. Medications will be stored in the classrooms in high shelves, in a backpack inaccessible to children or in the refrigerator in a locked box in room 2. All medications and first aid supplies will be inaccessible to the children. All toxins and other hazardous items will be stored in a locked cabinet in the classroom and will be inaccessible to children. There are 4 toilets ( 60 capacity) and _8_ sinks ( 120 capacity) accessible for children's use. The bathrooms were observed to be clean and with no health and safety hazards. Sinks accessible to children deliver water that is no warmer than 120 degrees. The program will provide a pitcher with water and cups for children to drink water indoors. Isolation of ill children will be located in room 108 which is across the hall from room 2. The staff bathroom will be used for an ill child. Report continues on the next page.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Glenn A Schnell
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
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: UMC PRESCHOOL-BURLINGAME
FACILITY NUMBER: 414004787
VISIT DATE: 06/09/2021
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Outdoor: The outdoor area measures 4546.481 sq ft. allowing for a total of 60 children. The outdoor area to be used is enclosed by at least a four foot fence and observed to be clean, safe and equipped with toys and equipment for children. Resilient material located under climbing applicable climbing structures is wood chips. There is pitcher and cups to allow children access to drinking water outside. Shade for children will be provided by shade structures.

The following items were reviewed as part of today's visit: Record keeping for staff, children and facility records, Care and Supervision of the Children, Child Discipline Procedures- staff will talk with the children and use redirection, Emergency Evacuation Procedures, Medication Policies, Isolation of Sick Children, Food Service, Transportation-none provided, Parents Rights, and Reporting Requirements. Required postings were observed during today's inspection. Facility will conduct monthly disaster drills and a log will be maintained for review upon request. The fire inspection was conducted, and approval was received on 5/25/21. The requirement for Lead Water Testing was discussed (H&S Code 1597.16). Information was provided to applicants during today's inspection. Advisory Note provided to applicants stating that the requirement for testing must be met by January 2023.

This facility will provide Incidental Medical Services – IMS. LPA reviewed storage area for medication and equipment/supplies, and reviewed forms that will be used. 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
Report Continues on the next page
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Glenn A Schnell
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
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: UMC PRESCHOOL-BURLINGAME
FACILITY NUMBER: 414004787
VISIT DATE: 06/09/2021
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The inspection included receiving a completed copy the the COVID-19 self-assessment guide and reviewing the document with the applicants. LPA also reviewed required postings during COVID-19. Applicant was informed that access to available Personal Protective Equipment (PPE) may be available through the local child care resource and referral agency.
Applicants signed this report electronically today. An electronic copy of this four page report will be emailed to both applicants at the conclusion of this inspection today.
LPA Schnell will recommend a 90-day provisional licensure of this facility for a capacity of 60 children once the following corrections/revisions are received:
-Influenza immunization records for Arlette and Victoria
-LIC 610
-LIC 9052 for Arlette
-Arlette needs to complete orientation component 2
-Admissions Policies
-Admissions Agreement
-Control of Property (signed/dated Lease Agreement)
-COVID-19 Self-Assessment
During the provisional license period, applicants agree to submit corrections to these additional application documents as required to complete the application process:
-Completion of EMSA Preventative Health Training course, and Lead Poison Training and Pesticides Training for Arlette and Victoria
-Financial Verification (LIC 404) needs to be received from the bank
-Job Descriptions
-Personnel Policies
-In-service Training Plan for staff
-Parent Handbook
-Discipline Policies
-Daily Activities Schedule
-Sample Menu
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Glenn A Schnell
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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