Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210106797
Report Date: 01/12/2016
Date Signed 01/12/2016 12:31:55 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:TWIN CITIES CCC AT NEIL CUMMINS SCHOOLFACILITY NUMBER:
210106797
ADMINISTRATOR:SCHAEFER, SANDRAFACILITY TYPE:
840
ADDRESS:58 MOHAWK AVENUETELEPHONE:
(415) 924-6622
CITY:CORTE MADERASTATE: CAZIP CODE:
94925
CAPACITY:90CENSUS: 56DATE:
01/12/2016
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Sandra FranzTIME COMPLETED:
12:45 PM
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2,LPA Ng conducted an unannounced random annual visit. LPA met with Sandra Schaeffer, Site Director during the visit. Facility is a school age program center. There were 56 children with 5 staff members. Sandra states that to her knowledge there are no known guns or weapons in the facility.
CLASSROOMS: Furniture and equipment are age appropriate and in good repair. There is adequate heating, lighting and ventilation. Drinking water is readily available via water dispensers and there is sufficient storage available for the children's belongings and sufficient space for the group size being served. There are separate toilet and sinks available for staff & children. Proper staffing ratios are maintained.
BATHROOMS AND TOILETING AREAS: Toilets flush. Faucets work. Toilets and sinks are reachable by children. Toilet paper, soap and towels are available and the bathrooms are clean. There is sufficient lighting and ventilation. Hot water was turned off.
INSPECTION OF FOOD SERVICE AREA: The school provides a snack to the children. The food is prepared on site. There is a food prep kitchen area, the food was inspected for freshness and all items were in compliance. The menu is posted but particular items are not listed.
INSPECTION OF OUTDOOR PLAY AREA: There are ample toys and activities for children. The facility has an outdoor area. The outdoor area has a large sand pit. The pit has a tarp. The flooring material is of concrete and asphalt.
HEALTH-RELATED SERVICES: Site Director states medications may be dispensed if a parent provides note and also is a prescription no over the counters. Medication is stored in upper cabinets inaccessible to children and lock boxes were observed for the placement of medications. There are first aid supplies and thermometer available. There are Earthquake emergency items available. Isolation is provided in the homework room with the use of one of the enclosed bathroom.
SUPERVISOR'S NAME: Suzanne Roman-ClarkTELEPHONE: (650) 266-8843
LICENSING EVALUATOR NAME: Tony NgTELEPHONE: 650-266-8843
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2016
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: TWIN CITIES CCC AT NEIL CUMMINS SCHOOL
FACILITY NUMBER: 210106797
VISIT DATE: 01/12/2016
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RECORDS: Children's and Staff's records were reviewed; All of the children's records were complete. Facility has posted the required forms (i.e. License, menus, waivers, Notification of Parent's Rights (updated) , Notification of Personal Rights, Car Seat Law, and Emergency Disaster Plan). Staff persons are current with First Aid/CPR certification. Site Director states Fire and Earthquake drills are done each month but did not have log to prove.
DISCIPLINE POLICY: Director states that they use redirection and talk to them.
DEFICIENCIES: No deficiencies observed.
SUPERVISOR'S NAME: Suzanne Roman-ClarkTELEPHONE: (650) 266-8843
LICENSING EVALUATOR NAME: Tony NgTELEPHONE: 650-266-8843
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2016
LIC809 (FAS) - (06/04)
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