Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430710194
Report Date: 09/27/2017
Date Signed 09/27/2017 06:48:47 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:BARRON PARK KIDS' CLUBFACILITY NUMBER:
430710194
ADMINISTRATOR:MITCHELL, KANDICEFACILITY TYPE:
840
ADDRESS:800 BARRON AVE.TELEPHONE:
(650) 856-1220
CITY:PALO ALTOSTATE: CAZIP CODE:
94306
CAPACITY:80CENSUS: 38DATE:
09/27/2017
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
04:10 PM
MET WITH:Kandice MitchellTIME COMPLETED:
06:50 PM
NARRATIVE
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Licensing Program Analyst (LPA), Janet Tse, conducted an unannounced random inspection to the Facility today. LPA met with Kandice Mitchell, director, and explained the nature of today’s visit to her. LPA toured the Facility both inside and outside today. 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. The Facility has active waivers for shared bathrooms with the school district and unfenced playground usage.

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 associated with the facility. 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 a staff (TJ) is without fingerprint clearances associated with the facility. There is no receipt confirmation to indicate that a criminal record transfer request has been received by Licensing. LPA contacted the San Jose Regional Office to verify the staff's previous association, and there is no record of the staff's association with this facility.

LPA observed the medical assessment and the Information and Emergency Information form (LIC 700) in ten children’s files. LPA observed the required health screening in five staff files. At least one staff present has current CPR and First Aid Certifications on file. 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 understands that children shall be visually supervised at all times. LPA reviewed the sign-in, sign-out sheets for the past 30 days and

Facility Evaluation Report dated 09/27/2017 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: 09/27/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2017
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 4
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: BARRON PARK KIDS' CLUB
FACILITY NUMBER: 430710194
VISIT DATE: 09/27/2017
NARRATIVE
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Facility Evaluation Report dated 09/27/2017 to be continued from previous page:

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. LPA conducted an exit interview with Director prior to the conclusion of today’s visit.

Deficiency was cited and civil penalty of $500 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: 09/27/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2017
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: BARRON PARK KIDS' CLUB
FACILITY NUMBER: 430710194
VISIT DATE: 09/27/2017
NARRATIVE
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Facility Evaluation Report dated 09/27/2017 to be continued from previous page:

Child Care Facility Roster (LIC 9040) and all were in compliance. LPA observed 38 children with three teachers, the assistant director, 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 and water dispensers. 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, stove top, and hot and cold running water. There is also adequate food for snacks for the children. The after school program only serves snacks. Cleaning supplies and poisons are stored inaccessible to the children. Any medications at the Facility are stored appropriately and in an off-limits area of the Facility. LPA reviewed the Facility’s medicine log and medication lock box during today’s visit. Currently, there is no children that requires medication.

LPA observed all furniture and equipment is in good condition and safe for the children. The outdoor surfaces of the playground area are safe for the children. LPA observed that the outdoor equipment is age appropriate and in good condition. There is also sufficient resilient materials (grass and poured rubber foam) in the outdoor playground area. LPA did not observe any bodies of water.

SB 792 Immunization Requirements was discussed. LPA observed required immunization records in file.
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. Currently, there is no children that needs IMS.

LPA also discuss Zero Tolerance with the immediate $500 civil penalty per violation and an ongoing $100 per day per violation continues until violation is corrected.

Facility Evaluation Report dated 09/27/2017 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: 09/27/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2017
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: BARRON PARK KIDS' CLUB
FACILITY NUMBER: 430710194
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/28/2017
Section Cited
CCR
101170(e)(2)
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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 request a transfer of a criminal record clearance from another facility or Trustline.
LPA observed a staff (TJ) is without fingerprint clearances associated with the facility.
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The after school program shall immediately forward a criminal record transfer request to associate the staff with the facility. The staff shall cease working at the facility until the fingerprint transfer is complete and her fingerprint clearance is associated with the facility
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Civil penalty of $500 is assessed.

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: 09/27/2017
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2017
LIC809 (FAS) - (06/04)
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