384003034-1-20-2022-05-CC-CQUO-CAUVB3-20220120151651

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 384003034
Report Date: 01/19/2022
Date Signed: 01/20/2022 03:17:31 PM

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:	SAN AGUSTIN, MICHELLE E.		FACILITY NUMBER:	384003034
ADMINISTRATOR:	SAN AGUSTIN, MICHELLE E.		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(626) 488-3931
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94131
CAPACITY:	14	CENSUS: 8	DATE:	01/19/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Licensee, Michelle Sn Agustin		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 January 19, 2022 at 9:15am, Licensing Program Analyst (LPA) Catrina Quimbo conducted an unannounced, annual, required inspection. LPA met with Licensee, Michelle San Agustin and explained purpose of inspection. Present in home were the Licensee, Licensee’s two helpers (H1 and H2) and 8 enrolled children (preschool age). Facility is operating within capacity limits and ratio on this date. All adults living and/or working in the home have a criminal record clearance on file. Hours of operation are Monday to Friday from 8:30am to 3:00pm. Licensee rents the home which is a multi-level, family home. The home consists of three levels. The DAY CARE AREAS are on the ground level of the home that includes a large classroom, multi-purpose room (napping and playroom), bathroom #1 and backyard area. The OFF-LIMIT areas are the upper two levels of the home and the garage. Off limit areas are barricaded with locked doors and/or child safety locks. At approximately 9:30am, LPA toured day care areas of home with Licensee. LPA observed home to be in good repair with proper temperature and ventilation. Day care operates as a Montessori program. There were a variety of age appropriate toys and equipment in the home which were in good condition. There were no pools, spas or bodies of water on the property. The backyard is enclosed with an least 5ft high fence. Backyard is equipped with appropriate outdoor toys and equipment that are in good working condition. All cleaning supplies, poisons and other chemicals were stored inaccessible to children on facility’s high cabinets and shelves. There was a working smoke detector and carbon monoxide detector, a fully charged fire extinguisher and a working telephone on site. Phone number listed for Licensee is current. Per Licensee, there are no weapons or firearms in the home. (Continue on Page 2...)

SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8864
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2022

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: SAN AGUSTIN, MICHELLE E.	FACILITY NUMBER: 384003034
	VISIT DATE: 01/19/2022

NARRATIVE

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LPA reviewed eight children’s records which were complete. Children’s file has a record of emergency identification information on file. LPA reviewed Licensee, H1’s and H2’s files which were complete. Licensee’s Pediatric First Aid/CPR is current and will expire 08/2022. Last emergency drill conducted was 12/2021. Emergency drills are conducted at least once every six months and are properly logged.

During inspection:
- Licensee was given information regarding PIN 20-24-CCP Safe Sleep Regulation, CA DPH Guidance for Use of Face Coverings, Receiving Important Updates, 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, frequent Visitors or Volunteers must be fingerprint cleared and associated to facility.
-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.

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.

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SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8864
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2022

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: SAN AGUSTIN, MICHELLE E.	FACILITY NUMBER: 384003034
	VISIT DATE: 01/19/2022

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.

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, Michelle San Agustin.

SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8864
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2022

LIC809 (FAS) - (06/04)

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