Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434408915
Report Date: 02/15/2019
Date Signed 02/21/2019 07:20:32 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: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: 73DATE:
02/15/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Kimberly KostepenTIME COMPLETED:
02:00 PM
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Licensing Program Analyst's (LPAs), Elizabeth Berumen and Araceli Almaraz, met with Director, Kimberly Kostepen to conduct an annual random inspection. LPA's inspected the indoor and outdoor areas of the physical plant. There are four classrooms utilized by the preschool children; rooms 2, 3, 4, and 5. Facility License, Parents’ Rights Poster, Personal Rights, Child safety seat law and Activity Schedules were observed to be posted. Facility's days and hours of operation are Monday to Friday from 7:30 AM to 6:00 PM.

LPA's reviewed 6 random children's files. The center utilizes their own version of the Identification and Emergency Information form (LIC 700). Files reviewed contained the Emergency Information form. LPA provided Director a copy of the Identification and Emergency Information form (LIC700).
Director has current CPR/First Aid certification with an expiration date of January 01/19/21. 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. LPA reviewed the sign in/out sheets in each classroom.

LPA's observed that the teacher/child ratio was in compliance during today's visit. Director, Kimberly Kostepen understands the conditions, limitations, and capacity specifications of the Facility license. Director understands that the children shall be visually supervised at all times and never left unattended.

LPA's inspected all areas accessible to children including rooms 2, 3, 4, and 5. The facility is safe, sanitary and in good repair. Drinking water is readily available for the children indoor via pitchers/disposable cups. The children's bathrooms and staff bathroom are clean, sanitary, and operable. Director states that there are no weapons or firearms on the premises.

REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #2 - REPORT DATED 02/15/19):
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Elizabeth BerumenTELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2019
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: HEADSUP! CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 434408915
VISIT DATE: 02/15/2019
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CONTINUATION OF PREVIOUS PAGE (PAGE #1 - REPORT DATED 02/15/2019):

The playground area is surrounded by appropriate fencing. Shade is provided through canopies and building overhang. Artificial grass is used as resilient material under the climbing structure. No bodies of water were observed. Outdoor drinking water is via pitchers and disposable cups.

A review of staff records during today's visit indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPA reminded Site Director of the 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 $3000.00 per person for any subsequent violations within a 12 month period.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


During the inspection, LPA discussed Senate Bill 792 (required immunization for employees or volunteers) and the required Mandatory Mandated Reporter Training (required every 2 years). Director agrees to file completion certificates of Mandated Reporter Training (AB1207 compliant) in each staff file.

LPA discussed immunization exemptions for measles and pertussis for staff. Per Heath and Safety code (H&S) 1597.622 (b) you must submit a written statement from a licensed physician declaring that because of your physical condition or medical circumstances, immunization is not safe. Or that you have evidence of current immunity to the diseases described in subdivision (a) of H&S 1597.622.

As a result of this inspection, no deficiency cited.
NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Elizabeth BerumenTELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2019
LIC809 (FAS) - (06/04)
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