Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430710045
Report Date: 09/15/2017
Date Signed 09/20/2017 02:25:48 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:
(650) 325-5350
CITY:PALO ALTOSTATE: CAZIP CODE:
94301
CAPACITY:80CENSUS: 29DATE:
09/15/2017
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Shruti SrinivasanTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs), Janet Tse and Fermin Campos-Jaramillo, conducted an unannounced random visit to the Facility today. LPA met with Shruti Srinivason, director, and explained the nature of today’s visit to her. LPA toured the facility both inside and outside during today’s visit. LPA observed the required posted materials, including the Facility License, Emergency Disaster Plan (LIC 610), Earthquake Preparedness Checklist (LIC 9148), Parents’ Rights Poster (PUB 393), Personal Rights (LIC 613A), Child Car Seat Law (PUB 269), Menus (includes current and following week), and Activity Schedule.

A review of staff records indicates that not all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPA also reminded them of the applicable civil penalties for those adults who have not received fingerprint clearance, are not associated to the license and who come in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violations within a 12 month period. LPA observed the director and the assistant director (GM) do not have fingerprint clearances associated with the facility. LPA verified with the San Jose Child Care Regional Office that neither the director nor the assistant director (GM) has fingerprint clearances in the LIS system.

LPA observed the medical assessment and the Information and Emergency Information form (LIC 700) in eight children’s files. LPA observed the required health screening in four staff files. Director has current CPR and First Aid Certifications in file (expiration date: September 2018). Director understands that there shall be at least one person, with valid CPR and First Aid certifications, on site at all times or present during off-site activities (field trips). LPA observed that the teacher/child ratio was in compliance during today’s visit. Director understands the conditions, limitations, and capacity specifications of the Facility license. Director

Facility Evaluation Report dated 09/15/2017 to be continued on next page: Page 1
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2017
This report must be available at Child Care and Group Home facilities for public review for 3 years.
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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
, 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: 09/15/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/16/2017
Section Cited
CCR
101215.1(m)
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Child Care Center Director Qualifications and Duties. A child care center director shall complete 15 hours of Health and Safety training.

LPA observed the director does not have the Health and Safety certification including one hour of nutrition training in file.
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The director shall obtain an EMSA approved certification for health and safety including one hour of nutrition and forward a copy of the certification to LPA by 10/16/2017 due date.
Type B
10/16/2017
Section Cited
CCR
101173(c)
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Plan of Operation.

This facility provides Incidental Medical Services (IMS). LPA observed no Plan of Operation for Incidental Medical Services approved by Licensing in file.
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Director shall submit a Plan of Operation for Incidental Medical Services to LPA by 10/16/2017 due 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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2017
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2017
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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
, 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: 09/15/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/18/2017
Section Cited
HSC
101170(e)(1)
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Criminal Record Clearance. Prior to working or volunteering in a licensed child care facility, all individuals subject to a criminal record review shall obtain a clearance or criminal record exemption.
LPA observed the director and the assistant director (GM) do not have fingerprint clearances associated with the facility.
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Director and assisant director shall immediately obtain fingerprint clearances through live scan.and must cease working for the day care center until fingerprint clearances is obtained and associated with the facility.

Civil penalty of a total of $600 is assessed.
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AB633 Parent Notification is required.
This page shall be provided to all parents of children currently enrolled and any future children being enrolled for the next 12 months per AB633 requirements.
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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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2017
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2017
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: 09/15/2017
NARRATIVE
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Facility Evaluation Report dated 09/15/2017 to be continued from previous page:

understands that children shall be visually supervised at all times. LPA reviewed the sign-in, sign-out sheets for the past 30 days and Child Care Facility Roster (LIC 9040) and all were in compliance. LPA observed one teacher and the assistant director Gladys Magpantay with eight children in Room 1 at arrival. Later during the visit, there were 12 children in Room 2 with one teacher and 17 children with one teacher and the director in Room 1.

LPA observed that all rooms are clean and safe for all children and staff. Director states that the school district cleans the Facility Monday through Friday in the evenings. Drinking water is readily available for the children in each room and in the outdoor playground area via drinking fountains. LPA observed solid waste containers with tight-fitting lids in each room and in the playground area. Staff and children’s bathrooms are clean, sanitary, and operable. There is a separate staff bathroom not utilized by the children which an isolated child can use if needed. Director states that there are no weapons on the premises.

The food preparation area is adequately equipped with ovens, refrigerators, and hot and cold running water. There is also adequate food for snacks for the children. Director states that children bring their own lunch and the after school program only provides snacks. Cleaning supplies and poisons are stored inaccessible to the children. Any medications at the Facility are stored appropriately in Room 1. Currently there is no children that requires medication at the facility.

LPA observed all furniture and equipment is in good condition and safe for the children. The playground area utilized by children is surrounded by appropriate fencing and the outdoor surfaces are safe for the children. LPA observed that the outdoor equipment is age appropriate and in good condition. There is also sufficient resilient materials (poured rubber foam) in the outdoor playground area. LPA did not observe any bodies of water. LPA observed the after school program is sharing the same playground with Walter Hays Elementary School at different schedules. A waiver request for shared playground use is needed. Director understands that there shall not be any commingling among the children from the after school program and Walter Hays Elementary School. A copy of the roster of children was provided to LPAs during the inspection.

LPA observed the director does not have the Health and Safety certification including one hour of nutrition training in file. LPA observed the required forms to be submitted to CCL for director qualification is not complete. A exception request for director qualification is needed.

Facility Evaluation Report dated 09/15/2017 to be continued on next page: Page 2
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2017
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: 09/15/2017
NARRATIVE
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Facility Evaluation Report dated 09/15/2017 to be continued from previous page:

LPA discussed Zero Tolerance with $500 immediate civil penalty and an ongoing of $100 per day per violation civil penalty will continue until the violation(s) is corrected.

Incidental Medical Services were discussed with the licensee. This facility provides Incidental Medical Services (IMS). LPA reviewed storage of medication and equipment /supplies, and reviewed children’s, personnel and administrative records. LPA observed no Plan of Operation for Incidental Medical Services approved by Licensing in file.

SB792 Immunization Requirements was also discussed. LPA observed the required immunization records for the staffs.

LPA discussed the requirements of AB633 to director and provided her the AB633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and director understands the requirements. Upon receipt, director shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.

Licensing Forms, Title 22 Regulations and Information can be obtained through the internet at www.cdss.ca.gov.

Deficiencies were cited. Civil penalty of $600 was assessed. Notice of site visit was issued and must be posted with type A deficiency cited for 30 days.


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SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2017
LIC809 (FAS) - (06/04)
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