Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434407984
Report Date: 10/13/2017
Date Signed 10/13/2017 10:56:08 AM

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:ABILITIES UNITED - MILESTONESFACILITY NUMBER:
434407984
ADMINISTRATOR:SOHEILA RAZBANFACILITY TYPE:
850
ADDRESS:3864 MIDDLEFIELD RDTELEPHONE:
(650) 618-3325
CITY:PALO ALTOSTATE: CAZIP CODE:
94303
CAPACITY:40CENSUS: 19DATE:
10/13/2017
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Soheila RazbanTIME COMPLETED:
11:15 AM
NARRATIVE
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An unannounced Annual/ Random inspection visit was made to the facility. Met with Soheila Razban, Vice president of the program. Reviewed staff and children's records at their administration office. All records were update. Discussed new immunization requirement with HR coordinator. Staff have updated CPR and First Aid certification. Staff files have copies of their educational background.
Toured two class room, Motor skill room and playground.
Furniture & equipment appear in good condition. Floors appear clean. Children's bathrooms are in good condition.
Trash can for food waste has a tight fitting cover. They serve two snacks and parents bring in children's lunches.
Today's snack is fruit and cracker.
Playground has age appropriate equipment and they have sand for their resilient material. They have accessible drinking water inside and outside.
Licensee stated that there are no fire arms in the facility. no bodies of water observed.
Reviewed sign in/ sign out sheet which matched number of children in care.
Incidental Medical Services were discussed with the licensee. The licensee is not providing IMS (Incidental Medical Services) at this time. Licensee will submit an updated plan of operation if in the future they provide any IMS services to a child in care.
A review of staff records on 10/12/2017 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemption. Soheila Razban applicable civil penalties for those adults who have not received fingerprint clearances, 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.
The following type B deficiencies are cited:
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: 10/13/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2017
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: ABILITIES UNITED - MILESTONES
FACILITY NUMBER: 434407984
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/13/2017
Section Cited
CCR
1597.622
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Health and safety 1597.622(a) (1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
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They need to update their immunization.
Type B
10/30/2017
Section Cited
CCR
101227(a)(6)
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101227 (a) (6)
menu shall be posted at least one week in advance in a place visible by child's authorized representative, dated and kept on file for 30 day, and made available upon request.
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They need to post their snack menu.
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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: 10/13/2017
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2017
LIC809 (FAS) - (06/04)
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