<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430702036
Report Date: 04/21/2023
Date Signed: 04/21/2023 02:49:34 PM

Document Has Been Signed on 04/21/2023 02:49 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:CHILDREN'S HOUSE OF LOS ALTOSFACILITY NUMBER:
430702036
ADMINISTRATOR:ELLA M. MAYONFACILITY TYPE:
850
ADDRESS:770 BERRY AVENUETELEPHONE:
(650) 968-9052
CITY:LOS ALTOSSTATE: CAZIP CODE:
94024
CAPACITY: 160TOTAL ENROLLED CHILDREN: 160CENSUS: 115DATE:
04/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Chris MayonTIME COMPLETED:
02:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 04/21/2023 at 9:15am, Licensing Program Analyst (LPA) Christina Uribe conducted an Unannounced Annual Required Inspection. LPA met with facility representative, Chris Mayon, also present at the time of the inspection were 21 staff & 115 children. The facility is within ratio & capacity compliance today. LPA provided facility representative the Entrance Checklist (LIC 125). The facility was toured to conduct a Health and Safety inspection. The facility currently operates 8:00am-5:15pm, Monday-Friday in 5 classrooms.

Classrooms: All classrooms were inspected for age-appropriate furnishings, equipment, & adequate storage for children’s belongings. LPA observed the cleanliness of floors & surfaces, the presence of a fully functional carbon monoxide detector, smoke detector/fire alarms, and a fully charged 3A40BC fire extinguisher that is accessible throughout the facility. The center is equipped with a fully stocked first-aid kit and available in the classrooms.

Food Service Areas: All center provided food items are properly labeled & stored separately from cleaning supplies. Food prep area is clean, adequately equipped, & free from hazardous materials. Snack menu is posted one week in advance, available for review, & dated. Solid waste bins equipped with tight fitting lid.

Bathrooms: Facility has separate staff and child designated bathrooms. Toilets and faucets are in safe and sanitary operating condition. The children are able to reach the sinks and toilets. Supplies are available.

Outdoor Play Area: There is a small water fountain in the play space which is accompanied by a waiver. There are no other bodies of water, or free-standing water accessible to children. There are age appropriate toys and materials for the children. The playground outside is fenced and all equipment and surfaces are free from hazards.

Page 1 of 3 ***Continued on LIC 809C***

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Christina Uribe
LICENSING EVALUATOR SIGNATURE: DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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: CHILDREN'S HOUSE OF LOS ALTOS
FACILITY NUMBER: 430702036
VISIT DATE: 04/21/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Records: All individuals subject to criminal record review have a clearance and have been associated to the facility. LPA reviewed 6 children’s files and 6 staff file. LPA reviewed the facility roster & personnel report. At least one opening/closing staff member has a current Pediatric CPR/First-Aid Certification. Mandated Reporter certificates were reviewed. The center is in compliance with sign in and out procedure. Emergency Drills are recorded and performed at least every six months. Per facility representative, there are no firearms on the premises. All required documents are posted in a publicly accessible area.

Facility representative stated that the facility is looking into transitioning to an electronic sign in and out system in the Fall of 2023. LPA Uribe stated that a waiver request will need to be submitted prior to this change. If interested, the facility will need to submit a waiver requesting to use an electronic sign in and out system by submitting the request to the licensing agency along with information on which digital system they would be using and how it would be utilized.

Health-Related Services: This facility does provide Incidental Medical Services (IMS). LPA inspected storage of medications and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual – Regulation Interpretations & Procedures for Child Care Centers sections 101173 & 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

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/process.

Facility representative 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.

Page 2 of 3 ***Continued on LIC 809C***

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Christina Uribe
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: CHILDREN'S HOUSE OF LOS ALTOS
FACILITY NUMBER: 430702036
VISIT DATE: 04/21/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Effective August 1, 2003 California Law requires Child Care Licensees to report unusual incidents or injuries to children in care to child’s parents and to the Department of Social Services using the Unusual Incident/Injury Form (LIC 624). Incidents must be reported within 24 hours to the regional office by phone and the written report, LIC 624, within 7 business days.

One Type B Violation cited during today's inspection. Please see deficiency page for additional information:

  • Type B Violation: Some children's prescription and/or non-prescription medications did not have a signed Parent Consent for Administration of Medication (LIC 9221) form.

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. Appeal rights were given and reviewed. Exit interview conducted and report was reviewed with the facility representative, Chris Mayon.

Page 3 of 3 ***End of Report***

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Christina Uribe
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/21/2023 02:49 PM - It Cannot Be Edited


Created By: Christina Uribe On 04/21/2023 at 12:09 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: CHILDREN'S HOUSE OF LOS ALTOS
FACILITY NUMBER: 430702036

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101226(e)(3)(B)
Health-Related Services
(3) Prescription medications may be administered if all of the following conditions are met: (B) For each prescription medication, the licensee shall obtain, in writing, approval and instructions from the child's authorized representative for the administration of the medication to the child.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview & record review, the licensee did not comply with the section cited above as some children did not have a signed Parent Consent for Administration of Medication (LIC 9221) form with their prescription and/or non-prescription medication which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2023
Plan of Correction
1
2
3
4
Facility will ensure that all medications have a signed Parent Consent for Administration of Medication (LIC 9221) form for each medication. Facility representative will email a copy of these signed forms to LPA Uribe at christina.uribe@dss.ca.gov no later than the due date of 05/19/2023.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Chandra Charles
LICENSING EVALUATOR NAME:Christina Uribe
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2023


LIC809 (FAS) - (06/04)
Page: 4 of 4