384001605-5-12-2022-05-CC-CQUO-CECQH4-20220512121030

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 384001605
Report Date: 05/12/2022
Date Signed: 05/12/2022 12:11:03 PM

Document Has Been Signed on 05/12/2022 12:11 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:	FORDE, KELLY E.		FACILITY NUMBER:	384001605
ADMINISTRATOR:	FORDE, KELLY E.		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(415) 641-4123
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94131
CAPACITY:	14	CENSUS:	DATE:	05/12/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Licensee, Kelly Forde		TIME COMPLETED:	12:45 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	On May 12, 2022 at approximately 9:00am, Licensing Program Analyst (LPA) Catrina Quimbo conducted an unannounced, annual inspection. LPA met with licensee, Kelly Forde, and explained the purpose of the inspection. Present in the home were licensee, T1, T2, licensee's minor child, and 12 enrolled children (all preschool age). Facility is operating within capacity limits and ratio on this date. All adults living and/or working in the home have criminal record clearance on file. Hours of operation are Monday to Friday from 8:00am to 5:00pm. Licensee owns the home with their family which is a multi-level, single family home. The home includes 3 levels. The DAY CARE AREAS are the backyard, entire second level of the home except the bathroom next to the kitchen and bedroom #1. The OFF-LIMITS AREAS are the first level of the home, third level of the home, bathroom next to kitchen and bedroom #1 (located on second level). With licensee, LPA inspected day care areas of the home for health and safety hazards. LPA observed the home to be clean, in good repair with proper temperature and ventilation. All cleaning supplies, poisons and other chemicals were not accessible to children in care. There were a variety of age appropriate toys and equipment that were in good condition. There was a working carbon monoixde detector, multiple smoke detectors, fully charged fire extinguisher, and fully stocked first aid kit on site. There is a working telephone on site. Phone number listed for licensee is current. Per licensee, there are no weapons or firearms in the home. Entire backyard is enclosed with an at least 5 ft high fence. LPA did not observe any pools, spas or bodies of water on site. Backyard area has age appropriate equipment that is in good working condition. There is a chicken coop that is properly barricaded, maintained and separated from children in care. (Continue on Page 2...)

SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022

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: FORDE, KELLY E.	FACILITY NUMBER: 384001605
	VISIT DATE: 05/12/2022

NARRATIVE

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LPA reviewed all twelve children's records which were complete. Children's records have a record of emergency identification information on file. LPA reviewed licensee, T1 and T2's records which were also complete. Licensee and staff all have record of required immunizations on file. Licensee has a current CPR certificate that will expire 01/2024. Emergency drills are conducted at least once every six months and are properly logged and documented. Last emergency disaster drill was conducted 04/14/2022.

During Inspection:
-Licensee was given information regarding PIN 20-24-CCP Safe Sleep Regulations and Lead Poisoning Facts Flyer.
-Licensee was reminded, as of September 1, 2016, all Staff and Volunteers must provide proof of immunization against pertussis, measles, and influenza, or qualifies for an exemption, pursuant to Health and Safety code 1596.7995 and 1597.622.
-Licensee was reminded about Mandated Reporter training available on CCLD website. Training must be completed every 2 years by all staff hired. Training can be taken online at www.mandatedreporterca.com.
-Licensee was reminded about the Provider Information Notices (PINs) on CCLD website.
-Licensee was advised for any additional questions to contact CCLD office, Monday to Friday, 8:00am - 5:00pm, (650) 266-8800 or 1 (844) 538-8766. Website: www.cdss.ca.gov

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: http://www.ada.gov/childqanda.htm

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SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022

LIC809 (FAS) - (06/04)

Page: 2 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: FORDE, KELLY E.	FACILITY NUMBER: 384001605
	VISIT DATE: 05/12/2022

NARRATIVE

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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.

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.

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.

No deficiencies were cited today under CCR, Title 22, Div. 12, Chapt. 1.

A notice of site visit was given and must remain posted for 30 days.

An exit interview conducted and report was reviewed with the licensee, Kelly Forde.

SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022

LIC809 (FAS) - (06/04)

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