Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414001244
Report Date: 02/18/2016
Date Signed 02/18/2016 05:01:07 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:CLUB HAPPY HALL, ROLLINGWOODFACILITY NUMBER:
414001244
ADMINISTRATOR:BOU-KHALIL, MARIAFACILITY TYPE:
840
ADDRESS:2500 COTTONWOOD DRIVETELEPHONE:
(650) 616-9054
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY:35CENSUS: 35DATE:
02/18/2016
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Mary JohnsonTIME COMPLETED:
05:05 PM
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Licensing Program Analyst (LPA) Pandora Huffman-Smith made an unannounced random annual inspection today and met with the acting director, Charina Reyes. The site director is not present today. Also present today are 2 staff and 35 school age children. The owner, Mary Johnson, was contacted and arrived approximately 40 minutes into the visit. The facility operates on the Rollingwood elementary school site Monday - Friday from 7:00 AM to 6:00 PM in classroom #16. LPA inspected the facility today indoor and outdoor for health and safety hazards and observed the following; the classroom is clean and furniture and equipment appears to be in good condition. There are 2 bathrooms adjacent to the classroom for children's usage; girls bathroom has 10 toilets and 6 sinks, boys bathroom has 5 toilets, 6 urinals and 6 sinks. The classroom has a first aid kit, fire extinguisher, and working telephone. The outdoor area is clean and all equipment appears to be in good condition. There is sufficient cushioning underneath the play structure. There is water available for children indoor and outdoor. LPA reviewed staff file, facility postings and staff CPR and first aid that expires October 25, 2016. The facility uses electronic sign in and out and there is also a tracking ratio log for staff to track teacher / child ratio. LPA provided the acting director with updated postings; LIC 393 (Notification of Parents Rights) and LIC 613 (Personal Rights).

There were no deficiencies cited today.
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8843
LICENSING EVALUATOR NAME: Pandora Huffman-SmithTELEPHONE: (650) 266-8843
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2016
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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