Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380505210
Report Date: 03/10/2017
Date Signed 03/10/2017 09:25:48 AM

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:ULLOA CHILDREN'S CENTERFACILITY NUMBER:
380505210
ADMINISTRATOR:WANG, CAILINGFACILITY TYPE:
840
ADDRESS:2650 42ND AVENUETELEPHONE:
(415) 759-8854
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94116
CAPACITY:120CENSUS: 38DATE:
03/10/2017
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
07:10 AM
MET WITH:Cailing Wang & Timothy LopezTIME COMPLETED:
09:35 AM
NARRATIVE
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2: Licensing Program Analyst (LPA) Huang met with Director Cailing Wang and Assistant Director Timothy Lopez for an Annual Random visit today at the facility. Present at the facility were also 2 other Teachers with 38 children in care. The program operates in a functioning school site, the SFUSD Ulloa Elementary School. Day care areas are: the tutoring room, the Gym, boys and girls bathrooms, and the outdoor playground. Facility meets teacher/child ratio today. LPA toured the facility for health and safety hazard. There are tables and chairs in the tutoring room for children to do their home work. The Gym area is adjacent to the tutoring room. The boys bathroom is in the Gym area with 2 urinals, two toilets and two sinks. The Girls bathroom is in the tutoring room that has 3 toilets and 2 sinks. There are also other two girls and two boys bathrooms available for children at the other side of the school by the playground area. The center provides snacks only and are prepared at the center. First aid supplies are available in the classroom. Isolation area will be in the kitchen area next to the classroom. At least one staff has current pediatric CPR and First Aid training. The center share the front part of the playground areas with the elementary school. There is a play structure with rubberized cushioning. Water is available for children during outdoor activity. Facility has posted the required forms (ie License, menus, Notification of Parent's Rights, Notification of Personal Rights, Car Seat Law, and Emergency Disaster Plan). Fire and Earthquake drills are done each month and are properly logged in the main office. All Children have signed in today. This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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/childqanda.htm. Facility will submit a written plan by the end of March this year. Facility was also informed that as of September 1, 2016, a person may not be employed or volunteer at a child care facility unless he or she has been immunized against influenza (once a year), pertussis (every 10 years), and measles (one time only) or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662.

Please see next page deficiency cited today under CCR,Title 22, Div. 12, Chapt. 1:
This report and rights to comment and appeal were discussed with the Director. This report must be kept in the facility available for public review. CCLD website: www.ccld.ca.gov Notice of site visit was posted. CCL website: www.ccld.ca.gov. For Provider Information Notice: ccld.ca.gov/PG5098.htm
SUPERVISOR'S NAME: Suzanne Roman-ClarkTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Karen HuangTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2017
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: ULLOA CHILDREN'S CENTER
FACILITY NUMBER: 380505210
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/28/2017
Section Cited
1596.7995
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Health and Safety code 1596.7995 and 1597.662
a person may not be employed or volunteer at a child care facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption.
LPA observed that staff do not have proof of all required Immunization on file.
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Licensee will ensure all staff and herself have been immunized against influenza, pertussis, and measles or qualifies for an exemption by the due date, 04/28/17.
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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: Suzanne Roman-ClarkTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Karen HuangTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2017
LIC809 (FAS) - (06/04)
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