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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380503488
Report Date: 10/17/2022
Date Signed: 10/17/2022 12:05:00 PM


Document Has Been Signed on 10/17/2022 12:05 PM - It Cannot Be Edited

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:SMITH, SHIRELFACILITY NUMBER:
380503488
ADMINISTRATOR:SMITH, SHIRELFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 846-8488
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94134
CAPACITY:14CENSUS: 6DATE:
10/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:11 AM
MET WITH:Shirel SmithTIME COMPLETED:
12:15 PM
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On October 17, 2022 at approximately 9:00 AM, Licensing Program Analyst (LPA) Nathan Garcia arrived at the facility to conduct an unannounced Annual Inspection on this day, and met with the Licensee, Shirel Smith. Purpose of the inspection was explained. Present were 6 children in care with the Licensee. 2 were infants and one of the children in care is the Licensee's great granddaughter. Licensee was operating in compliance to the required licensed capacity and ratio limits as of today. Per Licensee, the home is a 2 story, 3 bedrooms, 2 baths, kitchen, and dining room on the upper level; lower level had 2 bedrooms, 1 bath, and a big play area that was converted from a garage. LPA verified the background check clearance of the adults working or living in the home. The hours of operation are: M-F, 5:00 AM – 6:00 PM. Licensee provides breakfast, lunch, and PM snacks after nap time.
Daycare areas: Lower level living room and bathroom. Off Limit areas: All bedrooms and bathrooms on the upper level, 2 bedrooms, and backyard on the lower level. LPA and Licensee inspected the entire childcare area for Health and Safety hazards. LPA observed that off limit areas were locked and made inaccessible to the children in care by a barricade. There was a carbon monoxide and smoke detector in the home. LPA performed the tests to check the functionality of the detector. A fire extinguisher of size 3A40BC was also available in the home located in the hallway. First Aid kit is fully stocked and accessible. Per Licensee, there are no firearms or weapons or pets in the home. Licensee states, there are no pools or bodies of water in the home.

LPA observed that the house is in good repair and free of hazards with proper temperature and ventilation and lighting. LPA observed that there is a variety of age-appropriate toys, books, and other learning material available in the home for the children in care. There are a number of cots for the children to use during nap time and the Licensee provides coloring pages. Electric outlets have been secured with child protective covers, and a working phone is on site.

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SUPERVISOR'S NAME: Daniel J OquendoTELEPHONE: (650) 379-9023
LICENSING EVALUATOR NAME: Nathan GarciaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2022
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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: SMITH, SHIREL
FACILITY NUMBER: 380503488
VISIT DATE: 10/17/2022
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All posting requirements are met and posted near the childcare entrance. LPA reviewed facility records including all children's files present today. LPA observed that files have records of immunization, names, addresses and telephone numbers of each child's authorized representative. Licensee has LIC 282 signed notifying parents has no liability insurance. 3 children in care did not have files due to recent enrollment.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) / (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: www.ada.gov/childqanda.htm.



The Licensee was reminded about the Provider Information Notices (PINs) on the CCLD website. Licensees were informed that as of September 1, 2016, a person may not be employed or volunteer at a child care facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662. LPA reviewed AB 1207 with the Licensees. As of January 1, 2018, all staff must complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com. Effective July 1, 2020, Licensees must have proof of completion of EMSA certified lead poison training if applying for a change of location or capacity change to an existing license.

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SUPERVISOR'S NAME: Daniel J OquendoTELEPHONE: (650) 379-9023
LICENSING EVALUATOR NAME: Nathan GarciaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022
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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: SMITH, SHIREL
FACILITY NUMBER: 380503488
VISIT DATE: 10/17/2022
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LPA encouraged the Licensee to visit the Licensing website at www.ccld.ca.gov for licensing regulations and new updates. The Licensee can also email at childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list for the updates.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

A copy of this report was given to the Licensee and a site visit notification must be posted for 30 days.


Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the licensee, Shirel Smith
SUPERVISOR'S NAME: Daniel J OquendoTELEPHONE: (650) 379-9023
LICENSING EVALUATOR NAME: Nathan GarciaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/23/2022 02:16 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 11/23/2022 02:08 PM

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: SMITH, SHIREL
FACILITY NUMBER: 380503488

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(7)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in1 out of 1. 3 children in care does not have files such as LIC 700,627, and LIC995A and Immunization records, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/17/2022
Plan of Correction
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The licensee shall report to the Department any of the events as specified in CCR 102417(g)(7) that the children in care will complete record files by the due date of 11/17/22 to the LPA.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Daniel J OquendoTELEPHONE: (650) 379-9023
LICENSING EVALUATOR NAME: Nathan GarciaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 10/17/2022 12:05 PM - It Cannot Be Edited

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: SMITH, SHIREL
FACILITY NUMBER: 380503488

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4

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: Daniel J OquendoTELEPHONE: (650) 379-9023
LICENSING EVALUATOR NAME: Nathan GarciaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5