414000961-4-27-2022-05-CC-CQUO-CDVR4Z-20220427124220

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414000961
Report Date: 04/27/2022
Date Signed: 04/27/2022 12:43:11 PM

Document Has Been Signed on 04/27/2022 12:43 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:	CAMPBELL, TERESA LEE		FACILITY NUMBER:	414000961
ADMINISTRATOR:	CAMPBELL, TERESA LEE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(650) 635-6762
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94403
CAPACITY:	14	CENSUS: 12	DATE:	04/27/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Teresa Lee Campbell		TIME COMPLETED:	01:00 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 April 27, 2022 at approximately 9:45am, Licensing Program Analyst (LPA) Catrina Quimbo conducted an unannounced, annual, required inspection. LPA met with licensee, Teresa Lee Campbell, and explained the purpose of the inspection. Present in the home included licensee, licensee's teacher (T1), licensee's spouse and 12 enrolled children (2 infants and 10 preschool age). Licensee 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 8:00am to 5:30pm. Licensee owns the home which is a multi-level, family home. The home consists of 3 bedrooms, 2 and a half bathrooms, living room, backyard, cabin (located in backyard) and garage. The DAY CARE AREAS currently in use are the garage, bathroom #1, and backyard. The OFF-LIMIT AREAS are all bedrooms, bathroom #2, kitchen and living room. Off limit areas are completely separate from day care areas. At approximately 10:00am, LPA toured day care areas of home. LPA observed home to be in good repair with proper temperature and ventilation. There were a variety of age appropriate toys and equipment that were in good condition. All cleaning supplies, poisons and other chemicals were stored inaccessible to children on facility's high shelves or closed cabinets with high shelves. Entire backyard is enclosed with at least 5ft. high fence. There were no pools, spas or bodies of water on the property. LPA observed backyard to be equipped with appropriate outdoor toys and materials that were in good working condition. (Continue Report 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: 04/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2022

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: CAMPBELL, TERESA LEE	FACILITY NUMBER: 414000961
	VISIT DATE: 04/27/2022

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

(Continued, Page 2...)
There was a carbon monoxide detector, fire alarm installation, a fully charged fire extinguisher and a working telephone on site. Per Licensee, there are no weapons or firearms in the home.

LPA reviewed 12 children's records which were complete. Children's files have a record of emergency identification information on file. Licensee maintains a sign in/out sheet for each enrolled child. Children's records also have proof of lead poisoning facts flyer to have been provided to children's authorized representatives. LPA observed licensee also maintains safe sleep logs that are documented for each napping infant in care as well as infants' individual sleeping habit forms.

LPA reviewed Licensee and T1's files which were complete. Both licensee and T1 have a current Pediatric First/CPR certificate that will expire 01/2024. Both licensee and T1 have updated Mandated Reporter certificates that are current and will expire 12/2023. Both licensee and T1 have proof of required immunizations available for review.
Emergency drills are conducted at least once every six months and are properly logged. Last emergency drill conducted was 4/10/2022. Licensee also has a dog that is kept separate from day care areas. LPA reviewed dog's immunizations that were up to date.

During Inspection:
-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 about Mandated Reporter 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.

(Continue on Page 3...)

SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2022

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: CAMPBELL, TERESA LEE	FACILITY NUMBER: 414000961
	VISIT DATE: 04/27/2022

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

(Continue, Page 3...)
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, Chapt. 1.

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, Teresa Lee Campbell.

SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3