384002043-3-10-2022-05-CC-BVAN-CCDRJX-20220310120441

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 384002043
Report Date: 03/10/2022
Date Signed: 03/10/2022 12:06:08 PM

Document Has Been Signed on 03/10/2022 12:06 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:	FELLOM, JULIE ANNA		FACILITY NUMBER:	384002043
ADMINISTRATOR:	FELLOM, JULIE ANNA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(415) 971-4963
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94114
CAPACITY:	14	CENSUS: 4	DATE:	03/10/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Julie Fellom		TIME COMPLETED:	12:15 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 March 10, 2022, Licensing Program Analysts (LPA), Van conducted an unannounced required annual inspection and met with the Licensee, Julie Fellom. The purpose of the inspection was explained and granted entry to the home by the Licensee. There are four children in care with Licensee and two helpers today. All adults living or working in the home have a criminal background clearance on file. The house is a 3-floor building; Licensee's partner owns this building. Daycare areas are: a small kitchen area, bathroom, and the backyard on the lower level; the activity room is on the street level, and the playroom in the lowest level and has direct access to the back yard for outdoor activity. Per Licensee, the activity room is temporary not being used, currently used as storage, as the outside of the house is being painted. The off-limit areas are the entire top floor level, the storage, kitchen, and the garage on the street level. The Days and operation hours are 8:30 am – 3:00 pm, Monday – Friday. All off-limit areas, including closets, and staircase, are adequately barricaded. The Licensee states that if the children showed signs of illness, she will separate the child and have the child stay with the assistant in the garden area while contacting the parents to pick up the child. LPA and Licensee inspected the daycare areas for health and safety hazards during the inspection. The daycare area is clean, orderly, and equipped with safe, age-appropriate toys and equipment. LPA observed each child has individual storage space for their diapers and belongings. The home has adequate heating, lighting, ventilation and is free from defects or conditions that endanger children in care. The fireplace was observed to be screened off. The home has a smoke alarm & carbon monoxide detector, and fully charged fire extinguishers. All unused electrical outlets have a child-proof cover. Poisons, detergents, and cleaning compounds are stored inaccessible to children. All sleeping cots are stored appropriately. The Licensee states there are no firearms or weapons in the home. The Licensee has a pet dog, and all vaccinations are current. There are no pools, spas, or other bodies of water on the premises. LPA observed the Licensee had posted all the required forms, such as facility License, Notification of Parent's Rights, Earthquake Preparedness checklist, and Notification of Personal Rights.

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon Van	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

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

FACILITY NAME: FELLOM, JULIE ANNA	FACILITY NUMBER: 384002043
	VISIT DATE: 03/10/2022

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
26
27
28
29
30
31
32

Licensee states Fire and Earthquake drills are conducted every month. The last drill was conducted on March 1, 2022. Morning and afternoon snacks are provided to children. During the inspection, LPA reviewed the children's, Licensee's, and helper's records. LPA observed that the Licensee maintained records of each child accordingly; identification and emergency information, immunization, consent for medical treatment, and parent's rights were appropriately completed and maintained in their respective files. The Licensee and helper have a record of immunization. The Licensee and helper have valid Pediatric FirstAid and CPR training.

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 the Licensee and discussed the Child Care Licensing Safe Sleep webpage https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed the 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) was discussed with Licensee. For IMS information, see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: http://www.ada.gov/childqanda.htm

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon Van	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

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: FELLOM, JULIE ANNA	FACILITY NUMBER: 384002043
	VISIT DATE: 03/10/2022

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
26
27
28
29
30
31
32

The Licensee was reminded about the Provider Information Notices (PINs) on the CCLD website. Licensee was 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 Licensee. 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.

LPA encouraged the Licensee to frequently visit our 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.

During the inspection, the Licensee inquired about adding a co-Licensee. Information was provided to Licensee.

The report was reviewed and signed by the Licensee, Julie Fellom. No deficiencies were observed in today's inspection. Today's report, 3/10/2022, and notice of site visit will be sent to the Licensee email by the close of business on 3/10/2022. Confirmation of receipt is required, and a notice of site visit must remain posted for 30 days.

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon Van	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3