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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430700239
Report Date: 01/19/2024
Date Signed: 01/19/2024 03:26:00 PM

Document Has Been Signed on 01/19/2024 03:26 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:FIRST CONGREGATIONAL CHURCH NURSERY SCHOOLFACILITY NUMBER:
430700239
ADMINISTRATOR:JEFFRIES,CAROLYNFACILITY TYPE:
850
ADDRESS:1985 LOUIS ROADTELEPHONE:
(650) 493-1915
CITY:PALO ALTOSTATE: CAZIP CODE:
94303
CAPACITY: 60TOTAL ENROLLED CHILDREN: 60CENSUS: 0DATE:
01/19/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
01:02 PM
MET WITH: Marisa Cajbon TIME COMPLETED:
03:40 PM
NARRATIVE
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On 1/19/24 at 1:02 PM, Licensing Program Analyst (LPA) Michael Mathew conducted an unannounced Annual/Random inspection. LPA conducted the Covid-19 screening questions prior to entering the facility. LPA met with director Marisa Cajbon and advised her the purpose of the inspection. LPA was provided a tour of the facility inside and out. There were 0 children in care and 4 staff at the time of the inspection.

LPA observed required licensing documents mounted on the walls throughout the facility. LPA observed the center menu schedule which the facility provides morning snack. Fire drill was last conducted on 10/19/22. The center has four (4) classrooms available. At the time of inspection, No classrooms were in use. LPA observed enough restrooms available for children in care. LPA did not observe any hazards/toxins items accessible to children in care. There are no guns/weapons or ammunition at the facility. LPA observed no bodies of water. Each of the classrooms have age-appropriate toys and furniture readily accessible for children. The outdoor playground has ample amount of space for children to play. LPA observed tan bark under the play structure to help protect the children when they fall. LPA observed the playground has age-appropriate toys and structures available for children to use. The playground has an ample amount of shade available. Facility provides water for children in care.

A sampling of children and staff records were reviewed. LPA observed children's files to be complete and current. Currently the facility does have children that require Incidental Medical services (IMS). LPA observed staff files to be complete. LPA observed all staff members with a valid Mandated reporter certificate. LPA observed at least one person with a valid CPR/first aid certificate. LPA verified SB792 Child Care Adult Immunization and Tuberculosis requirements. LPA spoke with director about new Covid-19 guidelines. Facility is currently following Covid-19 guidelines.

Continued 809-C

SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Michael Mathew
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: FIRST CONGREGATIONAL CHURCH NURSERY SCHOOL
FACILITY NUMBER: 430700239
VISIT DATE: 01/19/2024
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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/

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.

Director Marisa Cajbon 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

LPA discussed the safe sleep regulations with Director Marisa Cajbon and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed licensee [or facility representative] of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

! type b deficiency were cited in today visit.

A notice of site visit was given and must remain posted for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted, appeal rights were given, and report was reviewed with Director Marisa Cajbon

SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Michael Mathew
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024
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Document Has Been Signed on 01/19/2024 03:26 PM - It Cannot Be Edited


Created By: Michael Mathew On 01/19/2024 at 03:11 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
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: FIRST CONGREGATIONAL CHURCH NURSERY SCHOOL
FACILITY NUMBER: 430700239

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care. LPA observed Fire drill was conduted on 10/19/22. Director stated that, Director had it planned but did not do it.
POC Due Date: 01/26/2024
Plan of Correction
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Director agreed to send completed Fire drill to LPA via email or text by end of day Friday 1/26/24
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:Wynn Norona
LICENSING EVALUATOR NAME:Michael Mathew
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2024


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