Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410509769
Report Date: 09/22/2017
Date Signed 09/22/2017 03:22:15 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:CSSF REC DEPT-SIEBECKER CENTERFACILITY NUMBER:
410509769
ADMINISTRATOR:ALENI CAPAZFACILITY TYPE:
850
ADDRESS:510 ELM COURTTELEPHONE:
(650) 875-6979
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:55CENSUS: 25DATE:
09/22/2017
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Aleni Capaz, Laura ArmaninoTIME COMPLETED:
03:30 PM
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LPA Andrea Medlin met with director and staff for this random annual licensing visit today. Purpose of the visit explained. There were 25 children present. Teacher-child ratio is in compliance. Days and hours of operation: Monday through Friday: 7:30AM-6:00PM. Physical plant toured to inspect for health and safety hazards. There are fully charged fire extinguishers that meet minimum requirements, smoke detectors, and a carbon monoxide (CO) detectors. Children's bathroom inspected; all toilets and hand washing facilities are in safe and sanitary operating condition. A separate staff bathroom is available. No pools, spas, hot tubs, fish ponds, or similar bodies of water are present. Per director, there are no firearms or weapons on site. Disinfectants, cleaning solutions, poisons and other items that are dangerous to children are inaccessible. Variety of age appropriate toys and materials for children are available. Classrooms are set up for child care and furniture and equipment for children is present. Cots are available for napping and are individually stored and labeled. Parent's provide the napping supplies and are responsible to wash once a week. Parent's provide meals; facility provides both morning and afternoon; sample menu is available and posted. Adequate first aid supplies are available. Sick children will be separated from the group while waiting for parents to pick up. Outdoor play area inspected for health and safety hazards. Outdoor activity spaces are enclosed by fences and surfaces are free of hazards. The areas around and under high climbing equipment is cushioned with tanbark. Facility has an outdoor playground waiver to use the adjacent public playground; center has exclusive use during their outdoor play time. Facility has posted all the required licensing forms. LPA reviewed staff and children's files. In the children’s files, each child had an admission agreement, Parent's Rights (LIC995), and current immunization records. In the staff files, each had verification of meeting the educational requirements, health screening with TB test, and the required staff immunizations. All staff have current Pediatric First Aid and CPR certification. Emergency drill was conducted in September 2017 and is appropriately logged. No apparent health and safety hazards observed during the visit. The facility appears to be clean and well maintained.

(continued on next page 809-C)
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Andrea MedlinTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2017
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 2
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: CSSF REC DEPT-SIEBECKER CENTER
FACILITY NUMBER: 410509769
VISIT DATE: 09/22/2017
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Incidental Medical Services (IMS) policy discussed. Facility has IMS on file. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA is 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 informed that effective 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, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662.

This report was reviewed with assistant child care supervisor and director and a copy of this report must be made available for public review upon request.

Notice of site visit observed posted and shall remain posted for 30 days.
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Andrea MedlinTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2017
LIC809 (FAS) - (06/04)
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