414002226-1-3-2024-05-CC-JTSE-CZ5TEX-20240103134041

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414002226
Report Date: 01/03/2024
Date Signed: 01/03/2024 01:41:03 PM

Document Has Been Signed on 01/03/2024 01:41 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
SAN BRUNO CC RO, 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: 3	DATE:	01/03/2024
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME BEGAN:	11:25 AM
MET WITH:	Licensee, Kumari Dong		TIME COMPLETED:	01:55 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 1/3/2024, at approximately 11:25AM, Licensing Program Analyst (LPA) Jonathan Tse conducted an unannounced annual visit at the facility. LPA was granted entry to the facility by Licensee, Kumari Dong. LPA explained the purpose of the visit. Present during the visit was the Licensee, three adult family members and three infants. The facility is in compliance with capacity requirements on this day. All adults living or working in the home have acquired fingerprint clearance and are associated to the facility. The facility’s operating hours are from Monday to Friday, 7:00AM to 6:00PM. Daycare Areas: Living Room, Kitchen, Dining Room, Bedroom #1, Bedroom #2, Bedroom #3, Bathroom #1 and Backyard. Off-limits Areas: Bedroom #4, Garage, and entire upper level. LPA inspected the home for any health and safety hazards. LPA observed the home to be equipped with age-appropriate toys and equipment. There is a fully charged 3A40BC fire extinguisher present in the kitchen. There is a combination smoke and carbon monoxide detector present. The first aid kit was observed to be fully stocked with materials necessary to administer first aid. Poisons, cleaning detergents and other chemicals are stored inaccessible to children. LPA observed cribs in Bedrooms #2 and #3 to be equipped with tight-fitted sheets that were clean. The cribs are free and clear of debris and other articles. Per Licensee, there are no firearms or weapons in the home. LPA observed the Backyard to be clean and free of debris. There is sufficient cushioning in the form of padded mats. The Backyard is enclosed by a fence that is at least five feet high. LPA reviewed five personnel files and three children’s files. LPA advised that all adults working with children in the home should complete Mandated Reporter Training. Licensee’s First Aid/CPR training expires 3/2025. LPA observed children’s files to contain Identification and Emergency Information (LIC700) and Consent for Emergency Medical Treatment (LIC627). LPA advised that all infants up to 12 months of age should have Individual Infant Sleeping Plans (LIC9227) present in their files. 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: 01/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024

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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Document Has Been Signed on 01/03/2024 01:41 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
SAN BRUNO CC RO, 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: 01/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1597.622(c)

Administration of Child Day Care Licensing

(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in five out of five personnel records which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/24/2024
	Plan of Correction
1 2 3 4	Licensee shall acquire immunization records for all adults working with children in the home and maintain them in the personnel files. Licensee shall submit proof of completion by submitting copies of immunization records to LPA by set due date of 1/24/2024.

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: Ali Zebila	TELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Jonathan Tse	TELEPHONE: (650) 464-4927
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024

LIC809 (FAS) - (06/04)

Page: 2 of 7

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: DONG, KUMARI & TAMANG, PREM B.	FACILITY NUMBER: 414002226
	VISIT DATE: 01/03/2024

NARRATIVE

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Page Two
LPA observed that the facility license was posted in a visible area of the Living Room. LPA provided copies of Notification of Parents’ Rights (PUB394) and Earthquake Preparedness Checklist (LIC9148) to Licensee during the visit. The facility provides breakfast, lunch, and snacks for children in care. Milk is provided for children when parents do not provide their own milk/formula from home.

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.

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.

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: 01/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024

LIC809 (FAS) - (06/04)

Page: 6 of 7

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: DONG, KUMARI & TAMANG, PREM B.	FACILITY NUMBER: 414002226
	VISIT DATE: 01/03/2024

NARRATIVE

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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.
See LIC809-D for deficiency cited today.
A notice of site visit was given and must remain posted for 30 days. Appeal rights were printed and provided to Licensee.

Exit interview conducted and report was reviewed with the Licensee, Kumari Dong.

SUPERVISOR'S NAME: Ali Zebila	TELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Jonathan Tse	TELEPHONE: (650) 464-4927
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024

LIC809 (FAS) - (06/04)

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