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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415328
Report Date: 04/13/2023
Date Signed: 04/13/2023 12:59:55 PM

Document Has Been Signed on 04/13/2023 12:59 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: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: 60CENSUS: 19DATE:
04/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:Kimberly KostepenTIME COMPLETED:
01:15 PM
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On 4/13/23 at 9:08 AM, 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 Kimberly Kostepen and advised her the purpose of the inspection. LPA was provided a tour of the facility inside and out. There were 19 children in care and 13 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 and afternoon snack. Fire drill was last conducted on 4/12/23. The center has six (6) classrooms available. At the time of inspection, 4 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. Facility provides children sleeping cots and cribs during nap time. LPA observed changing table arm’s length away from a sink. The outdoor playground has ample amount of space for children to play. LPA observed soft rubber padding 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, and the children have water bottles with their names on it for use.

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 observe IMS is kept in the classroom, in a backpack away and inaccessible to children in care. LPA also reviewed Correct IMS forms in child’s file. LPA observed staff files to be incomplete. LPA observed one staff member with and expired Mandated reporter 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 on 809-C

SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Michael Mathew
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 04/13/2023 12:59 PM - It Cannot Be Edited


Created By: Michael Mathew On 04/13/2023 at 12:07 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: STANFORD MADERA GROVE CHILDREN'S CENTER
FACILITY NUMBER: 434415328

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

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 staff files to be incomplete. LPA observed one staff member with and expired Mandated reporter certificate, Assistant director stated that Staff member forgot about training
POC Due Date: 04/21/2023
Plan of Correction
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Director agreed to send completed mandated reporter training certificate to LPA via email or text by end of day Friday 4/21/23
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: 04/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2023


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 EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: STANFORD MADERA GROVE CHILDREN'S CENTER
FACILITY NUMBER: 434415328
VISIT DATE: 04/13/2023
NARRATIVE
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Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation interpretations and procedures for Child Care Centers sections 101173 and 101226. When any IMS is provided, an updated plan of operation that includes IMS must be submitted to the Department. the follow 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.

PIN 22-06-CCP: Lead Testing in Child Care Centers – Frequently Asked Questions and Information on Lead Toxicity Prevention and Water Testing Information was discussed to director


Director 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.

1 type B deficiency was cited in todays 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 Kimberly Kostepen

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

DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023
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