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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434408916
Report Date: 10/17/2025
Date Signed: 10/17/2025 04:55:27 PM

Document Has Been Signed on 10/17/2025 04:55 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 CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:HEADSUP! CHILD DEVELOPMENT CENTERFACILITY NUMBER:
434408916
ADMINISTRATOR/
DIRECTOR:		BARBERIS, VITTORIAFACILITY TYPE:
830
ADDRESS:2800 WEST BAYSHORE ROADTELEPHONE:
(650) 424-1221
CITY:PALO ALTOSTATE: CAZIP CODE:
94303
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 7DATE:
10/17/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Baishakhi "Boi" HazarikaTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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On 09/15/2025 at 8:50am, Licensing Program Analyst (LPA) Jialing “Julianne” Zhu and Licensing Program Manager (LPM) Chandra Charles met with facility representative (FR) Baishakhi “Boi” Hazarika for an unannounced annual inspection. Present during the inspection were FR, three (3) fingerprint-cleared staff, and seven (7) children in care. The facility is within ratio and in compliance with capacity regulations today. Upon arrival, LPA provided director a copy of the Entrance Checklist (LIC 125). The facility was toured to conduct a Health and Safety Inspection. The facility’s current hours of operation are Monday - Friday from 8:00am - 6:00pm. The facility shares a campus with a preschool license (facility #: 434408915). The facility has separate indoor and outdoor spaces for infants and preschoolers.

Classrooms: This facility is licensed with one (1) classroom: Room 1. Room 1 is divided into five (5) areas: nap room for younger infants (with door), nap area for older infants, main play and learning area, alternate play and learning area, and food prep/dining area. The isolation area is a section of the classroom, away from other children in care. Classroom was inspected for age-appropriate furnishings, equipment, and adequate storage for children’s belongings. LPA observed the cleanliness of floors and surfaces. The facility is equipped with telephone service, smoke and carbon monoxide detectors, pull-down fire alarms, and fully charged 3A40BC fire extinguishers that are accessible throughout the facility. The alarms are serviced annually by the Palo Alto Fire Department. Fully stocked first-aid kits are available in the classroom. LPA inspected the napping equipment (sleep mats and bedding) and observed them to be stored in a healthful manner. Bedding is brought from home and returned home for washing weekly. Drinking water is accessible by children in the classrooms.

Infant Safe Sleep (ages 0-24 months): LPA observed there is one (1) crib with the correct-sized mattress and fitted sheet. Older infants sleep on mats. Infants are placed to sleep on their backs. 15-minute sleep checks are conducted and documented. Swaddles, including sleep sacks, are not used.

Page 1 of 3. See LIC 812C.

NAME OF LICENSING PROGRAM MANAGER: Chandra Charles
NAME OF LICENSING PROGRAM ANALYST: Jialing Zhu
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: HEADSUP! CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 434408916
VISIT DATE: 10/17/2025
NARRATIVE
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Food Service Areas: Meals are brought from home, and facility provides AM/PM snacks to infants in care. All center provided food items are properly labeled and stored separately from cleaning supplies. Food prep area is clean, adequately equipped, and free from hazardous materials. Snack menus are posted and were reviewed. Solid waste bins are equipped with tight fitting lids.

Bathrooms and Changing Stations: There are no bathrooms located in the infant component, but a changing table is available in Room 1 and is set-up and maintained according to Title 22 regulations. Staff have separate bathrooms from the children which are located in the hallway.

Outdoor Play Area: The outdoor play area is fully fenced. All equipment and surfaces are free from hazards. There is ample shade available. There are age-appropriate outdoor toys and materials for children. There are no play structures or climbing apparatuses in the designated infant outdoor play space. The ground is sufficiently padded with interlocking foam mats and is in good condition for safety. LPA observed two play areas with sand and are free from hazards. There are no pools or similar bodies of water on premises.

Files and Record Keeping Review: LPA reviewed the facility roster and personnel report, and copies were obtained. All individuals subject to criminal record review have a clearance and/or exemption and have been associated to the facility. LPA reviewed three (3) staff files. Every classroom has at least one (1) fully qualified teacher. At least one opening/closing staff member has a current Pediatric CPR/First-Aid Certification. Mandated Reporter Training certificates were reviewed and are current. LPA reviewed seven (7) infant files. The center utilizes an electronic sign-in/out system and is in compliance with sign-in/out procedures. However, the electronic sign-in/out system was not operational today, so a paper sign-in/out sheet was used. The last fire/disaster drill was an earthquake drill conducted on 10/16/2025. There are no firearms on the premises. All required documents are posted in a publicly accessible area.

Record Keeping and Reporting Requirements: Director was reminded that EMSA approved Pediatric CPR & First Aid training must be completed every two (2) years. Mandated Reporter Training ("Child Care Providers") is required for all staff and is to be renewed every 2 years by visiting https://mandatedreporterca.com/. Facility roster and personnel report must be properly maintained, and fire/disaster drills must be conducted at least every six (6) months and documented. 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 seven (7) business days. LPA informed Director that all forms can be downloaded at www.ccld.ca.gov.

Page 2 of 3. See LIC 812C.

NAME OF LICENSING PROGRAM MANAGER: Chandra Charles
NAME OF LICENSING PROGRAM ANALYST: Jialing Zhu
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2025
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
OAKLAND SOUTH CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: HEADSUP! CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 434408916
VISIT DATE: 10/17/2025
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Criminal Record Clearance: Director 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.

Lead Testing: Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test. LPA referred director to the Department website for lead: Lead Toxicity Prevention and Water Testing Information. This facility’s latest lead testing was completed on 08/26/2022 with no lead exceedances.

Incidental Medical Services (IMS): This facility does provide Incidental Medical Services (IMS). No infants enrolled at the facility as of today’s inspection require IMS. LPA observed there is a dedicated area to store medications where medications can be made inaccessible to children in care. 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)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at http://www.ada.gov/resources/child-care-centers/.

CCLD Information and Updates: Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

One (1) Type B deficiency and two (2) Advisory Notes were issued during today’s inspection.


Type B Deficiency: Children's files did not have a signed LIC 627 Consent for Medical Treatment form. The facility has an in-house form that is similar but does not have the same statement as the LIC 627.
Advisory Notes: 1 of 3 files reviewed by LPA did not have a LIC 503 Health Screening Report, but there is proof of a negative TB test on file; 2 of 7 infant files reviewed by LPA had immunization records that were not up-to-date.
A Notice of Site Visit was given and must remain posted for 30 days. Exit interview was conducted, report was reviewed, and Appeal Rights were provided to facility representative Boi Hazarika.

Page 3 of 3. End of Report.

NAME OF LICENSING PROGRAM MANAGER: Chandra Charles
NAME OF LICENSING PROGRAM ANALYST: Jialing Zhu
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/17/2025 04:55 PM - It Cannot Be Edited


Created By: Jialing Zhu On 10/17/2025 at 04:08 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: HEADSUP! CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 434408916

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101221(b)(8)(C)
Child's Records
(b) Each record shall contain information including, but not limited to, the following: (8) Medical assessment, including ambulatory status as specified in Section 101220, and the following health information: (C) A signed consent form for emergency medical treatment unless the child's authorized
representative has signed the statement specified in Section 101220(f).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above as children's files did not have a signed LIC 627 Consent for Medical Treatment form. The facility has an in-house form that is similar but does not have the same statement as the LIC 627 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/17/2025
Plan of Correction
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Facility representative will send signed LIC 627 forms for all 7 enrolled infants to LPA via email at jialing.zhu@dss.ca.gov on or before 11/17/2025.
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.
Chandra Charles
NAME OF LICENSING PROGRAM MANAGER:
Jialing Zhu
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2025


LIC809 (FAS) - (06/04)
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