Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434408915
Report Date: 02/16/2017
Date Signed 02/16/2017 11:19:27 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:HEADSUP! CHILD DEVELOPMENT CENTERFACILITY NUMBER:
434408915
ADMINISTRATOR:BOOTZ, TRACYFACILITY TYPE:
850
ADDRESS:2800 WEST BAYSHORE ROADTELEPHONE:
(650) 424-1221
CITY:PALO ALTOSTATE: CAZIP CODE:
94303
CAPACITY:120CENSUS: 64DATE:
02/16/2017
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Kimberly KostepenTIME COMPLETED:
11:20 AM
NARRATIVE
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An unannounced Annual Random visit was made to the facility. Met with newly hired Kimberly Kostepen. All of her paperwork have been faxed to out office.
Toured facility and observed arrival of children and staff. during arrival time and free play time.
Reviewed sign in/ sign out sheet which matched number of children in care.
Incidental Medical Services were discussed with Kimberly Kostephen. The program is providing IMS (Incidental Medical Services) at this time. Advised Kimberly Kostephen that they need to submit their IMS plan to licensing office by 03/13/2017. Today, they have no children on any medication.
Analyst did not see any bodies of water. Kimberly stated that there are no weapons at the Preschool.
Cleaning supplies are stored in the kitchen inaccessible to children.
Floors observed to be clean.
Children's bathrooms are in operating condition.
Facility provides two snacks and parents provide children's lunches. Reviewed posted menu. They prepare all snacks in the kitchen area of each room. Foods are stored properly. They have running hot and cold water. There are three refrigerator for preschool snacks.
Playground has climbing structures. They have tanbark for their resilient material. They have shaded areas in their playground.
They have accessible drinking water inside and outside.
Staff have current CPR & 1st aid cards valid until July 2018. Staff files have copies of their educational background.
Children's files have emergency information. Children were supervised during the visit. Teacher/child ratio was met during the visit.
Children nap at this program. They use mat for children. Children bring in their bedding.
Each child has an updated admission agreement.
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: 02/16/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2017
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 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: HEADSUP! CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 434408915
VISIT DATE: 02/16/2017
NARRATIVE
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The facility has a workable smoke alarm, carbon monoxide detector and fire extinguisher. Their last drill was on 12/29/2016.
They have no waivers.
A review of staff records on 02/16/2017 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.
Notice of site visit was posted and the notice must be up for 30 days.
The following type B deficiencies are cited
SUPERVISOR'S NAME: Timetra FaulconTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Roya ShahkaramiTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2017
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: HEADSUP! CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 434408915
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B

Section Cited
1596.7995
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(a) (1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center 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.
Employees lack all required immunization.
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Director will make sure that staff have all of their required immunization.
Type B
03/16/2017
Section Cited
101238(b)(1)
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101238(b)(1) Buildings and Grounds. All children shall be protected from hazards within the center through provisions of protective devices including but not limited to nonslip grips on rugs shall be provided.
Observed one a non slippery mat in the batrhoom of class room B with ripped bounding and holes.
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They will replace the mat by the 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: Timetra FaulconTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Roya ShahkaramiTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2017
LIC809 (FAS) - (06/04)
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