384001605-1-30-2024-05-CC-CQUO-CZYPAK-20240130100851

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 384001605
Report Date: 01/30/2024
Date Signed: 01/30/2024 10:08:56 AM

Document Has Been Signed on 01/30/2024 10:08 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 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: 12	DATE:	01/30/2024
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME BEGAN:	08:20 AM
MET WITH:	Kelley Forde		TIME COMPLETED:	10:20 AM

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 January 30, 2024 at approximately 8:20am, 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 during LPA's visit included 12 preschool children and 2 teaching staff. Licensee is a large license and is operating within capacity limits and ratio. Licensee lives in the multi-level home with their spouse and minor child. All adults living in the home and/or working in the home have fingerprint clearance on file. Hours of operation are Monday through Friday 8:00am to 5:00pm. The home consists of three levels. The DAY CARE AREAS are the backyard, entire second level of the home except bathroom next to kitchen and bedroom #1. The OFF LIMIT AREAS are the ground level of the home (pass through only), bathroom next to kitchen, bedroom #1 (located next to dining area), and entire third level of the home. LPA toured day care areas of home with licensee. LPA observed home to be in good repair with proper temperature and ventilation. Home is equipped with a variety of toys and materials that were observed to be in good working condition. The living room includes a fireplace that is properly barricaded and made inaccessible. Windows in living room include locks that are out of reach to children. Home is equipped with a fully charged fire extinguisher and multiple dual smoke/carbon monoxide detectors. Detector in playroom was tested during LPA's visit and was observed to be working. Bathroom for children's use was observed to be in proper working condition. LPA observed bathroom to include appropriate toileting equipment and sanitation products. Sink accessible to children does not provide water that is warmer than 120 degrees Fahrenheit. LPA observed poisons, chemicals and cleaning solutions to be made inaccessible in home's high shelves and/or behind child safety locked cabinets. Sharp objects in kitchen were made inaccessible. LPA observed cabinets in kitchen to include child safety locks. (Continue Report on Page 2...)

SUPERVISOR'S NAME: Marie Rodriguez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: FORDE, KELLY E.	FACILITY NUMBER: 384001605
	VISIT DATE: 01/30/2024

NARRATIVE

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LPA observe licensee to utilize cots for napping children. Cots were appropriately spaced from one another. Children's sheets are placed on cots so they are not touching each other. Entire backyard is fully enclosed and fenced. Outdoor area is equipped with a variety of toys and materials. LPA did not observe pools, spas or bodies of water.

LPA reviewed six random children's records which were complete. Children's files have required immunizations available for review. LPA also reviewed licensee and teaching staffs' files. Staff files have record of required immunization available for review. Licensee's CPR/First Aid is current and will expire 01/2025. LPA reminded licensee all staff working with children must have a current Mandated Reporter training certification that must be renewed every two years.

Licensee has licensing documentation properly posted and available for review. Licensee also maintains a child care roster that was made available for review. Emergency disaster drills are conducted at least once every six months. Last disaster drill was conducted November 16, 2023. Per licensee, there are no weapons or firearms in the home.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.
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SUPERVISOR'S NAME: Marie Rodriguez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: FORDE, KELLY E.	FACILITY NUMBER: 384001605
	VISIT DATE: 01/30/2024

NARRATIVE

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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-andresources/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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the licensee, Kelly Forde, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

No deficiencies were issued today during LPA's visit.

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

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

SUPERVISOR'S NAME: Marie Rodriguez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

LIC809 (FAS) - (06/04)

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