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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414002268
Report Date: 11/08/2019
Date Signed: 11/08/2019 10:33:24 AM

COMPREHENSIVE INSPECTION
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:SCULLY, ELIZABETH A.FACILITY NUMBER:
414002268
ADMINISTRATOR:SCULLY, ELIZABETH A.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 766-0869
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY:14CENSUS: 0DATE:
11/08/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Elizabeth ScullyTIME COMPLETED:
10:45 AM
NARRATIVE
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Licensing Program Analyst (LPA), Van conducted an unannounced annual inspection and met with Licensee, Elizabeth Scully. The purpose of the inspection was explained and was granted entry to the home by licensee. Present there is no children in care with licensee, licensee states she is on a mini vacation. Hours of operation are Monday-Friday from 8:30am to 5:30pm. LPA and Licensee inspected day care areas. Day Care Areas: entire first floor, garage and backyard. Off Limits Areas: second level of the home.

LPA and Licensee inspected the day care areas for health and safety hazards. LPA observed the following: Daycare area is clean, orderly, and equipped with age appropriate toys and equipment for the children. The home has adequate lighting and ventilation. Home has a working telephone, a working smoke and carbon monoxide detector, and a fully charged fire extinguisher. First aid supplies are available for children. Per licensee there are no firearms or weapons in the home. LPA observed no pools, spas or other bodies of water on the premises. All poisons, detergents, or cleaning products are inaccessible to day care children. LPA observed licensee has posted all the required forms (i.e. License, Notification of Parent's Rights, Notification of Personal Rights, and Emergency Disaster Plan). Fire drills are conducted and documented accordingly, last fire drill was conducted on 4/30/19. The licensee has complete records for children in care, including immunization records and Parents' Rights forms. Licensee Pediatric FirstAid & CPR will expire on 8/15/2021.

During inspection the following were discussed with licensee.
*Licensee was reminded about having all Staff and Volunteers provide proof of immunization against influenza, pertussis, and measles or qualifies for an exemption.
*Licensee was reminded about the Provider Information Notices (PINs) on CCLD website.
*Licensee was reminded about Mandated Reporter Training available on CCLD website (www.ccld.ca.gov or www.mandatedreporterca.com)
*Licensee was given information regarding ‘Safe Sleep’ practices.

No deficiencies were observed today. A copy of this report was reviewed and provided to the licensee. This report will be kept in the facility file and will be made available for public review upon request. Notice of Site Visit was observed to be posted and shall remain posted for 30 days.
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon VanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2019
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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