384002428-5-24-2023-05-CC-WLYY-CS5V6Y-20230524161016

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 384002428
Report Date: 05/24/2023
Date Signed: 05/24/2023 04:11:17 PM

Document Has Been Signed on 05/24/2023 04:11 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
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	ROOSVALL, NEGIN		FACILITY NUMBER:	384002428
ADMINISTRATOR:	ROOSVALL, NEGIN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(415) 265-6350
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94133
CAPACITY:	12	CENSUS: 4	DATE:	05/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Negin Roosvall		TIME COMPLETED:	10:30 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 May 24, 2023 at approximately 8:45am, Licensing Program Analyst (LPA) Ly conducted an Unannounced Required - 1 Year Visit to this family child care home and met with Licensee Negin Roosvall. Purpose of visit was explained. Present during the visit was Licensee caring for 2 preschool age children and 2 infant age children. Per Licensee Day Care Areas currently is just the living as there are not many children enrolled. Off Limit Areas in the home are the bedrooms and kitchen. Completed Child Abuse Mandated Reporter Training Certificate is on file and is valid until 07/2024. Per licensee, she had already renew her Pediatric CPR/First Aid but proof of completed training is not available to be review on this day. A Type B violation has been issued on this day in accordance with the California Code of Regulations, Title 22, see LIC 809D. LPA observed the home is clean orderly and properly ventilated. LPA also observed a 2A10BC Fire extinguisher, operable smoke detectors and carbon monoxide. There are no Fireplace or bodies of water in the home. Electrical outlets have child protective covers in place making them inaccessible to children. Chemical, detergents, cleaning compounds, medications, and other items of this nature are made inaccessible to children. Home has age appropriate toys and equipment available for the children in care. LPA reviewed children's files and all files are complete. All required posting documents are posted and visible. On this day, Licensee notified LPA that she will be permanently close her Family Child Care by the end of June 2023. Licensee was advised the procedures of closing her license. CONTINUED>>>

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Winnie Ly	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

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

FACILITY NAME: ROOSVALL, NEGIN	FACILITY NUMBER: 384002428
	VISIT DATE: 05/24/2023

NARRATIVE

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This family child care home does not provide Incidental medical Services to children in care. 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: http://www.ada.gov/childqanda.htm.

Licensee was also 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 discussed Child Abuse Mandated Reporter Training AB1207 with Licensee. As of January 1, 2018 all staff will be required to complete Child Abuse Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage athttps://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.

An exit interview was conducted and Plans of Corrections (POC) were developed and reviewed with Licensee. A copy of this report and appeal rights were discussed and left with Licensee whose signature on this form confirm receipt of reports. Notice of Site Visit was provided to licensee. Licensee was advised Notice of Site Visit to remain posted for 30 days. For updates on Licensing information, go to CCL website: www.ccld.ca.gov. For Provider Information Notice: ccld.ca.gov/PG5098.htm

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Winnie Ly	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/24/2023 04:11 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
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ROOSVALL, NEGIN	FACILITY NUMBER: 384002428
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102416(c)

Personnel Requirements

(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/07/2023
	Plan of Correction
1 2 3 4	Licensee will email proof of completed training of Pediatrc CPR/First Aid to LPA by due date 06/07/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Winnie Ly	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

LIC809 (FAS) - (06/04)

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