384003034-12-13-2022-05-CC-CQUO-CM3PR5-20221213103209

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 384003034
Report Date: 12/13/2022
Date Signed: 12/13/2022 10:32:41 AM

Document Has Been Signed on 12/13/2022 10:32 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
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: 10	DATE:	12/13/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:20 AM
MET WITH:	Michelle San Agustin		TIME COMPLETED:	10:45 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 December 13, 2022 at approximately 8:20am, Licensing Program Analyst (LPA) Catrina Quimbo conducted an unannounced, annual inspection. LPA met with licensee, Michelle San Agustin, and explained the purpose of the inspection. Upon LPA's arrival, facility had not yet opened and no children were present. Hours of operation are Monday to Friday 8:30am to 3:00pm. Licensee lives in the multi-level home. The home consists of three levels. Main entrance to the program is through door located on ground level of home. The DAY CARE AREAS are on the ground level of the home only which includes a large classroom, multi-purpose room (napping and gym room), bathroom #1, and backyard area. The OFF LIMIT AREAS located on the ground level of the home are the kitchen (pass by only), garage and upper two levels of the home. At approximately 8:30am, with licensee, LPA inspected day care areas of home. Facility operates as a Montessori program. LPA observed classroom to be equipped with a variety of Montessori toys and equipment that were age appropriate and in good working condition. The home is in good repair with proper temperature and ventilation. LPA observed electrical outlets in day care areas to be made inaccessible with child safety covers and/or blocked by furniture. Cleaning supplies, poisons and other chemicals were stored inaccessible to children behind child safety locked cabinets or stored in home's high shelves. LPA observed garbage and compost bins to have tight fitting lids. At approximately 8:45am, LPA observed two teachers and 10 enrolled children (preschool age) to be present during LPA's visit. Home is operating within capacity limits and ratio during LPA's visit. All adults working and/or living in the home have criminal record clearance on file. 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) 266-8800
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022

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: 12/13/2022

NARRATIVE

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Entire backyard area is fully fenced with an at least 5 ft. high fence. LPA observed stairs in backyard area were made inaccessible with a child safety gate. LPA did not observe any pools, spas or bodies of water on the property. Backyard is equipped with appropriate outdoor toys and equipment that are in good working condition. There is a play structure in backyard that was observed to have resilient padding underneath with artificial turf.

LPA reviewed 6 children's records, which were complete. Children's files have a record of emergency identification information on file. LPA reviewed licensee and both teachers' files which were also complete. Both licensee and teachers have record of required immunizations that were made available for review. Licensee has a current CPR certificate that will expire 11/2024. Both licensee and teachers present have a current Mandated Reporter certificate that will expire in 11/2024.

Last emergency disaster drill was conducted 10/26/2022. Emergency drills are conducted at least once every six months and are properly logged. Licensee maintains an updated child care roster for all children present. LPA observed all required licensing documents to be properly posted and available for review near front door entrance.

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

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
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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: 12/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022

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: 12/13/2022

NARRATIVE

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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. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the licensee, Michelle San Agustin.

SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022

LIC809 (FAS) - (06/04)

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