414002226-8-17-2022-05-CC-CQUO-CHDUGN-20220817153439

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414002226
Report Date: 08/17/2022
Date Signed: 08/17/2022 03:34:50 PM

Document Has Been Signed on 08/17/2022 03:34 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:	DONG, KUMARI & TAMANG, PREM B.		FACILITY NUMBER:	414002226
ADMINISTRATOR:	DONG, KUMARI & TAMANG, PRE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(650) 312-8504
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94403
CAPACITY:	14	CENSUS: 4	DATE:	08/17/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Kumari Dong		TIME COMPLETED:	04:00 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 August 17, 2022 at approximately 1:30pm, Licensing Program Analyst (LPA) Catrina Quimbo conducted an unannounced, annual inspection. LPA met with licensee, Kumari Dong, and explained the purpose of the inspection. Present in the home included licensee and 4 enrolled children (3 infants and 1 preschool age). Facility is operating within capacity limits and ratio during LPA's visit. Hours of operation are Monday to Friday from 7:00am to 6:00pm. Licensee lives in the home with co-licensee, licensee's adult children and licensee's children's spouse. The home is a multi-level, single family home. The DAY CARE AREAS are the living room, kitchen, dining area, bedroom #1, bedroom #2, bedroom #3, bathroom #1 and backyard (all located on first level of home). The OFF-LIMITS AREAS are bedroom #4 (located on first floor), entire upstairs of home and garage. All off limit areas are made inaccessible to children by locked doors and child safety gates. At approximately 1:50pm, 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 in the home which were in good condition. All cleaning supplies, poisons and other chemicals were stored inaccessible to children on home's shelves and/or locked behind child safety locked cabinets. Home contains a fireplace and is barricaded by furniture and soft cushioning. LPA observed home to have a smoke and carbon monoxide detector, fully charged fire extinguisher, fully stocked first aid kit and a 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 least 4ft high fence. Outdoor area is also equipped with materials that is age appropriate and 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: 08/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022

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: DONG, KUMARI & TAMANG, PREM B.	FACILITY NUMBER: 414002226
	VISIT DATE: 08/17/2022

NARRATIVE

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LPA reviewed four children's records, whom were present during inspection. No children's files were complete with a record of emergency identification information on file or consent for medical emergency. Per licensee, forms are complete, however, licensee was unable to provide proof of completed forms to LPA during visit.

Licensee's Pediatric First Aid/CPR is current and will expire 03/2023. Licensee has proof of documented safe sleep documents for napping infants in care. LPA reminded licensee documentation for each napping infant must include 15 minute time checks of infant as well as infants sleeping position.

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.

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.

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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: 08/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: DONG, KUMARI & TAMANG, PREM B.	FACILITY NUMBER: 414002226
	VISIT DATE: 08/17/2022

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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-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.

Licensee was cited a Type B citation for incomplete children's records. Please see 809D for more information.

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.

An exit interview conducted and report was reviewed with the licensee, Kumari Dong.

SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/17/2022 03:34 PM - It Cannot Be Edited

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: DONG, KUMARI & TAMANG, PREM B.	FACILITY NUMBER: 414002226
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(7)

Operation of A Family Child Care Home

(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not having an emergency identification card for any enrolled child, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/09/2022
	Plan of Correction
1 2 3 4	LPA reviewed list of documents that need to be maintained for all enrolled children. Licensee to update children's records to have an emergency information identifcation card for each enrolled child. Licensee to provide LPA proof of updated children's records no later than September 9, 2022 by 5:00pm.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022

LIC809 (FAS) - (06/04)

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