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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415328
Report Date: 04/01/2022
Date Signed: 04/01/2022 10:45:48 AM

Document Has Been Signed on 04/01/2022 10:45 AM - 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:STANFORD MADERA GROVE CHILDREN'S CENTERFACILITY NUMBER:
434415328
ADMINISTRATOR:ZARCONE, SALLYFACILITY TYPE:
830
ADDRESS:751 OLMSTED ROADTELEPHONE:
(650) 721-6632
CITY:STANFORDSTATE: CAZIP CODE:
94305
CAPACITY: 60TOTAL ENROLLED CHILDREN: 34CENSUS: 24DATE:
04/01/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:Ridhima KhannaTIME COMPLETED:
11:04 AM
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On 4/1/2022, Licensing Program Analyst (LPA) Jonathan Williams arrived at the facility unannounced for the purposes of conducting a Case Management inspection regarding an Unusual Incident Report filed by the facility. LPA was met by Program Director, Ridhima Khanna. Present for today's inspection are 15 fingerprint cleared and associated staff members and 24 infants in care.

Facility staff submitted an Unusual Incident Report on 3/16/2022. The Report stated that facility staff called 9-11 in response to a child turning blue and running a high fever. Program Director stated to LPA that the child was not hospitalized, has fully recovered, and has returned to daycare.

Program Director was reminded that California Law requires licensed Child Care Centers 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). Program Director was reminded that incidents must be initially reported within 24 hours by phone, fax, or electronic mail and that the LIC624 must be submitted to the Department within 7 days in a readable format.

No deficiencies cited. Exit interview conducted. Appeal rights provided.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Jonathan Williams
LICENSING EVALUATOR SIGNATURE: DATE: 04/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/01/2022
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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