Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434412177
Report Date: 10/23/2015
Date Signed 10/23/2015 05:31:20 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:CLUB J AT THE OSHMAN FAMILY JCCFACILITY NUMBER:
434412177
ADMINISTRATOR:MALLARE, CYRUSFACILITY TYPE:
840
ADDRESS:3921 FABIAN WAYTELEPHONE:
(650) 223-8788
CITY:PALO ALTOSTATE: CAZIP CODE:
94303
CAPACITY:154CENSUS: 134DATE:
10/23/2015
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Dave RosenfieldTIME COMPLETED:
05:36 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
2
An unannounced Annual/ Random visit was made to the facility. Met with site supervisor, Dave Rosenfield and together we toured facility. Toured 7 room and two playgrounds.
Rooms are: G103, G100, M117, D 117 ( they share with ps), D120, D123 and M 121.
Observed children in the playground as well as in class room.
Observed arrival of children and a staff person signed the children in.
Observed children during snack time, outside play time and free play time. Observed children being supervised in all of their class room and playgrounds
They have a waiver for bathroom . Discussed terms and condition of the bathroom.
They have a waiver for their playground. Discussed terms and condition
Reviewed posted snack menu in their parents' area.
Reviewed sampling of staff and children's records.
They have conducted their emergency drill on 10/07/2015.
There is a working phone in the facility.
Dave stated that there is no firearm in the facility.
No bodies of water was observed.
Observed accessible drinking water inside and outside.
They have fake grass and sand for their resilient material.
Staff have an updated CPR training.
The facility does administer medication for one child who has an allergy. Medication is stored in a locked container.
Discussed Incidental Medical Services and gave Dave a copy of regulation. They need to submit an IMS plan by 11/23/15.
The following type B deficiencies are cited:
See next page.
SUPERVISOR'S NAME: Timetra FaulconTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Roya ShahkaramiTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2015
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: CLUB J AT THE OSHMAN FAMILY JCC
FACILITY NUMBER: 434412177
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2015
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/30/2015
Section Cited
101238(a)
1
2
3
4
5
6
7
101238(a) Buildings and Grounds. The child care center shall be clean, safe, sanitary and in good repair at all times.
Observed row of stacked chairs in M121.
Not safe for children.
1
2
3
4
5
6
7
They need to remove all stacked chair and not use the room for storage.
Type B
12/23/2015
Section Cited
101238.3(b)
1
2
3
4
5
6
7
101238.3(b) Indoor Activity Space. All floors shall be safe and clean.
Observed dirty carpet in room D-120
1
2
3
4
5
6
7
They need to deep clean or replace the carpet by the due date.
Type B
10/30/2015
Section Cited
101239(f)
1
2
3
4
5
6
7
101239(f) Fixtures, Furniture, Equipment and Supplies. Solid waste shall be appropriately stored, located, and disposed of in a manner that will not transmit communicable diseases, or odors, create a nuisance, or provide a breeding place or food source for insects and rodents.
Observed garbage cans with food remain that did not have a tight fitting lids.
1
2
3
4
5
6
7
They need to purchase garbage can with tight fitting lid.
Type B
10/30/2015
Section Cited
101227(a)(18)
1
2
3
4
5
6
7
101227 (a)(18) All kitchen, food-preparation and storage areas shall be kept clean and free of litter and rubbish; and measures shall be taken to keep all such areas free of rodents and other vermin.
Observed dirty refregerato in M-120.
1
2
3
4
5
6
7
They need to clean refrigerator.
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: 10/23/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2015
LIC809 (FAS) - (06/04)
Page: 2 of 3