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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415328
Report Date: 09/13/2024
Date Signed: 09/13/2024 02:37:16 PM

Document Has Been Signed on 09/13/2024 02:37 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:STANFORD MADERA GROVE CHILDREN'S CENTERFACILITY NUMBER:
434415328
ADMINISTRATOR/
DIRECTOR:		ZARCONE, SALLYFACILITY TYPE:
830
ADDRESS:751 OLMSTED ROADTELEPHONE:
(650) 721-6632
CITY:STANFORDSTATE: CAZIP CODE:
94305
CAPACITY: 60TOTAL ENROLLED CHILDREN: 60CENSUS: 42DATE:
09/13/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:05 PM
MET WITH:Kimberly KostepenTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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On 09/13/2024 at 12:05pm, Licensing Program Analyst (LPA) Jialing “Julianne” Zhu met with Director Kimberly Kostepen for an unannounced annual continuation inspection. This inspection is a continuation of the annual inspection conducted on 09/12/2024. (See LIC 809 from 09/12/2024.) The information presented in this report is collected and observed from the initial annual inspection and the continuation inspection today. Present during the inspection were director, assistant Infant-Toddler director, 17 fingerprint-cleared staff, and 42 children in care. The facility’s current hours of operation are Monday - Friday from 7:00am - 6:30pm. The facility shares a campus with a preschool license (license #434415329). The facility has an indoor and outdoor space for infants that are physically separate from space used by the preschool license.

Physical Plant: This facility is operated in two buildings (Acorn House and Mulberry House) that are connected by the outdoor play area between the two buildings. There are carbon monoxide detectors, smoke detector/fire alarms, and fully charged 3A40BC fire extinguishers that are accessible throughout the facility. Carbon monoxide detectors and smoke detectors/fire alarms were not tested by the LPA during the inspection. The isolation area for when children are sick is the lobby. A teacher will be supervising the child while they are waiting for parent pick-up. The wellness room is used as an additional isolation area.

Classrooms: This facility has six (6) infant classrooms, and all are currently in use. All classrooms were inspected for age-appropriate furnishings, equipment, and adequate storage for children’s belongings. LPA observed the cleanliness of floors and surfaces, The center is equipped with a fully stocked first-aid kit and available in the classrooms. LPA inspected the napping equipment and observed them to be stored in a healthful manner. Cribs are available for infants with the correct size mattresses and fitted sheets. Bedding is provided by the facility. LPA reviewed documentation of 15-minute checks when infants are napping. Drinking water is accessible by children in the classrooms. LPA observed changing tables and the surrounding area are maintained according to Title 22 Regulations.

Page 1 of 3. See LIC 812C.

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Jialing Zhu
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2024
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
Document Has Been Signed on 09/13/2024 02:37 PM - It Cannot Be Edited


Created By: Jialing Zhu On 09/13/2024 at 01:25 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: 09/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101430(a)(3)(A)(4)(a)
Infant Care Activities
(A) Staff shall place infants up to 12-months of age on their backs for sleeping. (4) Infants with an Individual Infant Sleeping Plan [LIC 9227 (3/20)] that have Section C of the form completed and signed by an authorized representative shall be placed on their back when first laid down to sleep. In the event the infant changes position, the infant may remain in the alternative position. (a) Upon staff observation that the infant is capable of rolling from their back to their stomach and stomach to their back, the provider shall fill out Section D of the Individual Infant Sleeping Plan [LIC 9227 (3/20)], notify the authorized representative, and obtain the authorized representative's signature on the individual sleeping plan no later than the next business day following observation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as 3 infant files of infants under the age of 12 months were reviewed by LPA. All 3 infant files had LIC 9227 with Section D not filled out and signed, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/11/2024
Plan of Correction
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Director will email the LIC 9227 of the 3 infants signed by parents to LPA at jialing.zhu@dss.ca.gov by 10/11/2024.

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:Jialing Zhu
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2024


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: STANFORD MADERA GROVE CHILDREN'S CENTER
FACILITY NUMBER: 434415328
VISIT DATE: 09/13/2024
NARRATIVE
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Food Service Areas: The facility provides AM/PM snacks to children in care. Children bring meals from home. 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. Infants' bottles were storde in the classroom's refrigerator. Snack menus are posted inside the classrooms. Solid waste bins are equipped with tight fitting lids.

Outdoor Play Area: The playground outside is fully fenced and all equipment and surfaces are free from hazards. There is ample shade available. There are age-appropriate outdoor toys and materials for the children. The ground is sufficiently padded with turf or rubber padding and in good condition for safety. Drinking water is accessible by children outdoors. There are no bodies of water, or free-standing water accessible to children.

Files and Record Keeping Review: LPA reviewed the facility roster and personnel report. LPA observed the facility roster did not have the enrollment dates filled out for some children. All individuals subject to criminal record review have a clearance and/or exemption and have been associated to the facility. LPA reviewed six (6) staff files. LPA signed three (3) LIC 9095 Evaluation of Teacher Qualifications today. At least one opening/closing staff member has a current Pediatric CPR/First-Aid Certification. Director’s Pediatric CPR/First Aid Certification expires on 02/2025. Mandated Reporter Certificates were reviewed and are current. Director’s Mandated Reporter Certificate is current and expires on 02/2025. LPA reviewed five (5) children’s files. The center uses an electronic sign-in/out system. Fire/disaster drills are performed at least every six months, the last drill was a fire drill conducted on 08/08/2024. Per director, 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/. Personnel and facility roster 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 3 of 3. See LIC 809C.

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Jialing Zhu
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024
LIC809 (FAS) - (06/04)
Page: 3 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 CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: STANFORD MADERA GROVE CHILDREN'S CENTER
FACILITY NUMBER: 434415328
VISIT DATE: 09/13/2024
NARRATIVE
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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.

Incidental Medical Services (IMS): This facility does provide Incidental Medical Services (IMS). LPA inspected storage of medications and equipment/supplies, and reviewed children’s, personnel, and administrative records. All children’s medications were inspected to ensure that they are securely stored, accompanied by their original packaging, and are in compliance with expiration dates. 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/.


One (1) Type B deficiency was issued during today’s inspection.

Type B Deficiency:

· 3 infant files of infants under the age of 12 months were reviewed by LPA. All 3 infant files had LIC 9227 with Section D not filled out and signed.

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 Director Kostepen.

Page 3 of 3. End of Report.

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Jialing Zhu
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2024
LIC809 (FAS) - (06/04)
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