Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414001244
Report Date: 12/06/2017
Date Signed 12/06/2017 03:50:26 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:60CENSUS: 38DATE:
12/06/2017
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Site Director, Maria Bou-KhalilTIME COMPLETED:
04:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPAs), Cindy Interiano and Elvira Sierra, conducted an Annual/Random Inspection this day and met with Site Director, Maria Bou-Khalil. Purpose of the visit was explained. Program operates M-F: before-school, 7a-9:30a and after-school, 12:15p-6:00p during the School year calendar in Room #15 and the Multipurpose room at the Rollingwood Elementary School Site. Program is closed during summer, winter, and spring breaks. Present during the visit is Site Director and 3 staff caring for 38 School Age children. Facility was inspected indoors and outdoors for Health and Safety hazards. Classroom has age appropriate toys and equipment that are in good repair. Program uses sections of the Elementary School Playground. Children are not allowed to go beyond the set boundaries of the playground, unless it is supervised by a staff. Outdoor play area is free of debris and dangerous conditions. All outdoor toys and equipment are age appropriate and in good repair. Cubbies are used to store children’s belongings and are located inside the classroom. Classroom is equipped with a smoke and carbon monoxide detector. Classroom has proper ventilation and sufficient lighting. Children’s restrooms are located in the hallway. Girls’ restroom has 10 toilets and 6 sinks. Boys’ restroom has 6 urinals, 6 toilets, and 6 sinks. Program has exclusive use of the children’s restroom. Restrooms are maintained clean, in good repair and with adequate supplies. Drinking water is readily available indoors and outdoors. Program provides daily snacks. Classroom has appropriate postings. Last Emergency Drill was conducted on 12/06/17 and is properly logged. First Aid Kit and Emergency supplies are properly maintained and kept inaccessible to children. Cleaning products and Toxins are maintained inaccessible to children. LPA reviewed Staff files and are complete, including immunization.

See Page 2. . .
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2017
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: CLUB HAPPY HALL, ROLLINGWOOD
FACILITY NUMBER: 414001244
VISIT DATE: 12/06/2017
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Page 2. . .

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. 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 was 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, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662.

Site Director was reminded of Pesticides training. For More information about changes to the Healthy Schools Act, templates, or articles, you can inspection the DPR website at: www.cdpr.ca.gov/shoolipm/childcare.

Site Director was informed about the Provider Information Notices (PINs) on CCLD website.

***No deficiencies were cited against the facility under CCR,Title 22, Div. 12, Chapt. 1. ***

>This report and rights to comment and appeal were discussed with Site Director. This report must be available in the facility for public review. Notice of site inspection was posted.
Site Director was advised any additional questions to call Office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website: www.ccld.ca.gov
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2017
LIC809 (FAS) - (06/04)
Page: 2 of 2