Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430710045
Report Date: 10/20/2017
Date Signed 10/20/2017 04:15:58 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: 14DATE:
10/20/2017
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:David CarlsonTIME COMPLETED:
04:20 PM
NARRATIVE
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LPA Janet Tse met with director David Carlson for a case management inspection regarding an unusual incident reported to and received by Licensing on 10/18/2017. Present was also assistant director Shruti Srinivasan. The principal of Walter Hays Elementary School, Mary Bussman, was informed on 10/09/2017, that three children in Walter Hays Kids' Club were watching inappropriate images on a personal IPhone while playing under a fort they had built during after school care about a year ago. The exact date of the incident could not be identified. Assistant director states that the incident could have happened between September 2016 and May 2017. The principal was made aware of the incident when a mother shared this information with someone at a school social this year. The after school care was not aware of the incident prior to the meeting with Walter Hays Elementary School principal which was requested by the principal. There was absence of visual supervision resulting inappropriate behavior to occur, which is a Zero Tolerance violation. Director states that the after school care is no longer using fort building as one of their activities. The after school program also does not permit the use of electronic devices any longer and has changed the wi-fi password. If children need to contact parents, they would have to use the center's phone.

LPA observed 14 children with one teacher, director and assistant director during today's inspection.

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.

Deficiency was cited and civil penalty of $150 was assessed. Date of incident cannot be identified; therefore date of incident on the civil penalty assessment form will apply to 05/31/2017. Notice of site visit was issued and must be posted with type A deficiency cited for 30 days.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2017
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/20/2017
Section Cited
CCR
101229(a)(1)
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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).
An incident occurred last year (2016) that there was absence of visual supervision resulting inappropriate behavior to occur.
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The after school care shall ensure that activities shall be designed in manners that staff will be able to visually observe children's behavior at all times. Director shall forward a written plan of correction to LPA regarding plans and methods to conduct children's activities to ensure that children are visually supervised at all times.
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This is a Zero Tolerance violation.
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An immediate civil penalty of $150 was assessed. The incident occurred prior to July 2017. A conference will be scheduled.
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: 10/20/2017
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2017
LIC809 (FAS) - (06/04)
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