414001557-6-15-2022-05-CC-CQUO-CFEU64-20220615151741

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414001557
Report Date: 06/15/2022
Date Signed: 06/15/2022 03:18:18 PM

Document Has Been Signed on 06/15/2022 03:18 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:	DUBOIS, KARLA M.		FACILITY NUMBER:	414001557
ADMINISTRATOR:	DUBOIS, KARLA M.		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(650) 571-5054
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94403
CAPACITY:	14	CENSUS: 13	DATE:	06/15/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Karla Dubois		TIME COMPLETED:	03:30 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 June 15, 2022 at approximately 12:15pm, Licensing Program Analyst (LPA) Catrina Quimbo conducted an unannounced, annual inspection. LPA met with licensee, Karla Dubois, and explained the purpose of the inspection. Present during inspection included licensee, licensee's two adult children, licensee's minor child, 1 adult helper (H1), 1 minor helper (H2), and 13 enrolled children (10 preschool age, 3 infants, and 1 school age). Licensee is operating within capacity limits and ratios during LPA's visit on this date. All adults living and/or working in the home have fingerprint clearance on file. Hours of operation are Monday through Friday 7:00am to 6:00pm. License owns the single-level, single family home with licensee's spouse. The home includes 4 bedrooms, 2 bathrooms, living room, dining area, kitchen, backyard and garage. The DAY CARE AREAS are the kitchen, living room, dining area, bathroom #1, bedroom #2 (playroom), bedroom #3 (napping room only), bedroom #4 (napping room only) and backyard. The OFF LIMITS AREAS are bedroom #1/office (pass by only), bathroom #2, and garage. All off limit areas are properly barricaded with child safety locked door handles. At approximately 12:30pm, LPA toured day care areas of home with licensee for health and safety hazards. Home is in good repair with proper temperature and ventilation. There were a variety of age appropriate toys and equipment in the home which were in good condition. LPA observed all cleaning supplies, poisons and other chemicals to be stored inaccessible to children on facility's high shelves and/or locked behind child safety cabinets. Home is equipped with a combination smoke and carbon monoxide detector, fire extinguisher and working phone on site. Phone number listed for licensee is current. Per licensee, there are no weapons or firearms in the home. LPA did not observe any pools, spas or bodies of water on the property. The backyard is enclosed with an at least 5 ft, high fence. Backyard is equipped with appropriate outdoor toys and equipment that are 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: 06/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2022

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: DUBOIS, KARLA M.	FACILITY NUMBER: 414001557
	VISIT DATE: 06/15/2022

NARRATIVE

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LPA reviewed thirteen children's records which were complete. Children's files have a record of emergency identification information on file. Licensee's Pediatric First Aid/CPR is expired, however, is scheduled to renew course 06/18/2022. Licensee provided LPA proof of registration for renewed course. Licensee will provide LPA proof of completed certificate once course is complete on 06/18/2022. Emergency drills are conducted at least once every six months and are properly logged. Last emergency drill conducted was 06/14/2022.

During Inspection:
- Licensee was given information regarding PIN 20-24-CCP Safe Sleep Regulation 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 about Mandated Reporter training that can be taken online at www.mandatedreporterca.com. Training must be completed every 2 years by all staff hired.
-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.

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 Care Homes Sections 101173 and 101226. 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: 06/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2022

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: DUBOIS, KARLA M.	FACILITY NUMBER: 414001557
	VISIT DATE: 06/15/2022

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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, 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, Karla Dubois.

SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2022

LIC809 (FAS) - (06/04)

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