414000961-12-14-2023-05-CC-JTSE-CYHR55-20231214114232

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414000961
Report Date: 12/14/2023
Date Signed: 12/14/2023 11:42:45 AM

Document Has Been Signed on 12/14/2023 11:42 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
SAN BRUNO CC RO, 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: 5	DATE:	12/14/2023
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Licensee, Teresa Campbell		TIME COMPLETED:	11:45 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 12/14/2023, at approximately 8:45AM, Licensing Program Analyst (LPA) Jonathan Tse conducted an unannounced annual visit at the facility. LPA was granted entry to the facility by Licensee, Teresa Campbell. LPA explained the purpose of the visit. Present during the visit was the Licensee, Licensee’s spouse, Licensee’s adult son, a helper (H1), two infants and three preschool age children. All adults living or working in the home have fingerprint clearance and are associated to the facility. The facility’s operating hours are 8:00AM to 5:30PM, Monday to Friday. The facility is a three-bedroom, two-bathroom home. Daycare Areas: Garage (converted into play/nap area), Bathroom #1, and Backyard. Off-limits Areas: Bedroom #1, Bedroom #2, Bedroom #3, Bathroom #2, Kitchen, Living Room, Dining Room, and Cabin in Backyard. LPA and Licensee inspected the home for health and safety hazards. LPA observed the daycare areas to be in clean and orderly condition. The home is equipped with a fully charged 2A10BC fire extinguisher. There is a carbon monoxide detector and a smoke detector present in the home. There is a first aid kit present in Bathroom #1 that is fully equipped. The Garage is converted into a napping and play area. There is a loft present in the Garage. The stairs leading to the loft are secured by a childproof barrier. The facility provides linens for children to nap in and washes them once a week. LPA observed there to be age-appropriate toys and learning materials present in the play/napping areas. Cleaning supplies, poisons, and other chemicals are stored inaccessible to children. There is no fireplace present in the daycare areas. Per Licensee, there are no firearms in the home. Continued on Page Two

SUPERVISOR'S NAME: Ali Zebila	TELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Jonathan Tse	TELEPHONE: (650) 464-4927
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

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

FACILITY NAME: CAMPBELL, TERESA LEE	FACILITY NUMBER: 414000961
	VISIT DATE: 12/14/2023

NARRATIVE

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The Backyard as a play structure that is age-appropriate for children in care. There is artificial turf that provides sufficient cushioning. The Cabin in the Backyard is locked and kept inaccessible to children. There are age-appropriate toys that were observed to be in good repair. There is a pet dog present in the home.

LPA reviewed two personnel files and five children’s files. All personnel files were observed to be complete. Licensee’s First Aid/CPR training expires 1/2024. Licensee’s Mandated Reporter Training expires 12/2025. Immunization records are available for review. All children’s files were observed to be complete and include Identification and Emergency Information in addition to complete immunization records.

LPA observed all required postings to be posted in the entryway to the facility. Emergency drills are properly documented and logged. The last emergency drill was conducted on 9/29/2023. The facility prepares lunch for children who do not bring their own lunch from home. AM/PM snacks are offered as well.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Continued on Page Three

SUPERVISOR'S NAME: Ali Zebila	TELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Jonathan Tse	TELEPHONE: (650) 464-4927
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

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

FACILITY NAME: CAMPBELL, TERESA LEE	FACILITY NUMBER: 414000961
	VISIT DATE: 12/14/2023

NARRATIVE

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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-andresources/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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, Licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

No deficiencies were cited during today's visit.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee, Teresa Campbell.

SUPERVISOR'S NAME: Ali Zebila	TELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Jonathan Tse	TELEPHONE: (650) 464-4927
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC809 (FAS) - (06/04)

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