Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430710045
Report Date: 08/26/2016
Date Signed 08/26/2016 05:09:03 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:WALTER HAYS KIDS' CLUBFACILITY NUMBER:
430710045
ADMINISTRATOR:CHASE, CHRISTINAFACILITY TYPE:
840
ADDRESS:1525 MIDDLEFIELD ROADTELEPHONE:
(415) 325-5350
CITY:PALO ALTOSTATE: CAZIP CODE:
94301
CAPACITY:80CENSUS: 32DATE:
08/26/2016
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Christina ChaseTIME COMPLETED:
05:35 PM
NARRATIVE
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Roya Shahkarami met with Site Director, Christina Chase, for an annual random visit. While walking toward portable observed one child going from one portable to another without any visual supervision. Later three other children walked from one portable to another. Analyst look inside the portable and observed teachers' back toward the door. On second portable , director was serving snack and was not able to supervise the children.
This is a violation of Zero tolerance and civil penalty of $150 was assessed.
The following type A deficiency is cited, see the next page for citation.
Analyst toured facility both indoor and outdoor. All the required forms including the facility license, Notification of Parents' Rights, menus, activity schedule and earthquake check list observed to be posted.
Analyst reviewed sampling of staff and children's records. Staff have current CPR training.
Today, the teacher/ child ratio was in compliance.
Analyst observed functioning smoke detectors and a carbon monoxide detector at the facility. Their last emergency drill was on 06/02/2016.
They have accessible water fountain for children inside the class room and in the playground.
Cleaning products are stored in a locked cabinet under the sink in each room inaccessible to children. Analyst reviewed sign in/out sheets which matched number of children in care.
Christina stated that there are no weapons on the premises.
Analyst did not observe any bodies of water.
Reviewed posted snack menu and today's snack was varieties of food, celery, macaroni salad, trail mix, cheese , cold cut, chips, bread, sunflower oil and carrots.
Food preparation area is equipped with microwave, refrigerator, dishwasher and a sink with hot and cold running water. Garbage containers have tight fitting lids.
They have two bathrooms in one of the portable and they can use the school's bathroom.
See next page for continuation of the report:
SUPERVISOR'S NAME: Timetra FaulconTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Roya ShahkaramiTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2016
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: WALTER HAYS KIDS' CLUB
FACILITY NUMBER: 430710045
VISIT DATE: 08/26/2016
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They use the school playground. Play ground has age appropriate equipment.
Discussed Incidental Medical Services (IMS) with Christina and they have no children on any medications.
A review of staff records on 08/26/2016 indicated that all staff have their required clearances.
The following type A deficiency is cited:
Notice must be up for 30 days.
SUPERVISOR'S NAME: Timetra FaulconTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Roya ShahkaramiTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2016
LIC809 (FAS) - (06/04)
Page: 3 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: WALTER HAYS KIDS' CLUB
FACILITY NUMBER: 430710045
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2016
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/12/2016
Section Cited
101229(a)(1)
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101229(a)(1) Care and Supervision. No child(ren) shall be left without the supervision, including visual observation, of a teacher at any time except as specified in sections 101216.2(e)(1) and 101230(c)(1).
$ children walked on different time from one portable to another without any visuual supervsion. As soon as the staff person saw analyst, she stood by doorway with her walkie talkie.
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A written plan of correction is requested by the due date. The plan should clearly identify steps to prevent such incident from reoccurring in future.
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THIS REPORT MUST BE GIVEN TO ALL CURRENT AND FUTURE PARENTS AND THEY NEED TO SIGN LIC 9224 FOR ONE YEAR FROM TODAY'S DATE.
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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: Timetra FaulconTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Roya ShahkaramiTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2016
LIC809 (FAS) - (06/04)
Page: 2 of 3