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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214005458
Report Date: 08/21/2019
Date Signed: 08/28/2019 11:10:32 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:BAKER, TEREIFACILITY NUMBER:
214005458
ADMINISTRATOR:BAKER, TEREIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 747-5582
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:14CENSUS: 5DATE:
08/21/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Licensee, Terei BakerTIME COMPLETED:
04:20 PM
NARRATIVE
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THIS IS AN AMENDED REPORT TO REMOVE THE TYPE A VIOLATION FROM 8/21/2019.

Licensing Program Analyst (LPA), Luis J. Gomez met with Licensee, Terei Baker. Purpose of the inspection was explained and was for an Annual/Random inspection. Present in the facility is Licensee and helper caring for 5 children. ( 4 Infants 0 PreK 1 School age ). Licensee is within capacity limits of the large license. Licensee’s rents home which is a 3- bedroom, 2- bathroom, 2- level house. Hours of Operation are: Mon- Fri: 7:30 am- 5:30pm. Daycare areas are: Garage (Playroom), Bedroom #1, Bathroom #1 and Backyard Area. Off Limit areas are: Living Room, Kitchen and Entire upstairs area (Bedroom #2, Bedroom #3 and Bathroom #2). All off limit areas are properly barricaded with child safe gates. There are no bodies of water or fireplace in the Daycare area. LPA Gomez observed the following: Daycare area is clean, orderly, and equipped with age appropriate toys, books, puzzles and equipment for the children. Home has ample lighting and ventilation. Home has a working telephone, a working smoke and carbon monoxide detector, and a fully charged 2A10BC fire extinguisher. There are no poisons, detergents, cleaning products, or sharp objects accessible to daycare children. Licensee states there are no guns or weapons in the home. LPA Gomez inspected the backyard for health and safety hazards. Backyard is equipped with toys and equipment that are good repair. Licensee’s cardiopulmonary resuscitation certifications expires: June, 2020 (Per Pre-licensing Report). Licensee stated she is not conducting or logging emergency disaster drills once every 6- months. Licensee stated that parents are providing all daily snacks and meals for children. LPA Gomez observed all required postings are properly posted next to the main door. Licensee stated she and her husband have 2 pets in the home ( Dog and Cat). Licensee stated that all pet have their vaccinations. LPA Gomez reviewed the children’s files and facility roster during today’s inspection. LPA Gomez observed Children’s files and Facility roster is complete and up-to-date.
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SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8832
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 393-9134
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2019
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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: BAKER, TEREI
FACILITY NUMBER: 214005458
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/28/2019
Section Cited

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102417(g)(9)(A)(1) Operation of a Family Child Care Home. All homes shall conduct fire and disaster drills at least once every six months and document the date and time of each drill. This requirement is not met as evidence by.
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Based on observations and interview with licensee, facility is not conducting and logging emergency disaster drills once every 6-months. This is a potential health and safety risk to children in care.
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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: Alma MaligTELEPHONE: (650) 266-8832
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 393-9134
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2019
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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: BAKER, TEREI
FACILITY NUMBER: 214005458
VISIT DATE: 08/21/2019
NARRATIVE
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Page 2. . .
During inspection,
*Incidental Medical Services (IMS) policy was discussed.
*Licensee was reminded about having all Staff and Volunteers provide proof of immunization against influenza, pertussis, and measles or qualifies for an exemption.
*Licensee was reminded about the Provider Information Notices (PINs) on CCLD website.
*Licensee was reminded about Mandated Reporter Training available on CCLD website (www.ccld.ca.gov or www.mandatedreporterca.com)
*Licensee was given information regarding ‘Safe Sleep’ practices.

>See attached deficiencies page for deficiencies issued today under Title 22 Division 12 of the Ca. Code of Regulations.

This report and rights to comment and appeal were discussed with Licensee. This report must be available in the facility for public review. Notice of site visit was observed being posted. Licensee was advised any additional questions to call Office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website: www.cdss.ca.gov
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8832
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 393-9134
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2019
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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: BAKER, TEREI
FACILITY NUMBER: 214005458
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/21/2019
Section Cited

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THIS IS AN AMENDED REPORT TO REMOVE THE TYPE A CITATION
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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: Alma MaligTELEPHONE: (650) 266-8832
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 393-9134
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2019
LIC809 (FAS) - (06/04)
Page: 4 of 4