414002986-5-27-2021-05-CC-GLEG-C42VT9-20210616164242

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 414002986
Report Date: 05/27/2021
Date Signed: 05/27/2021 04:47:36 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/03/2021 and conducted by Evaluator Brendon Van

PUBLIC

COMPLAINT CONTROL NUMBER: 05-CC-20210503130155

FACILITY NAME:	KOZACZUK, PETER		FACILITY NUMBER:	414002986
ADMINISTRATOR:	KOZACZUK, PETER		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(650) 344-6925
CITY:	BURLINGAME	STATE: CA	ZIP CODE:	94010
CAPACITY:	14	CENSUS: 6	DATE:	05/27/2021
		ANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Peter Kozaczuk and Adriana Ruiz Sanchez		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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-Licensee is not allowing parents to go inside the facility

INVESTIGATION FINDINGS:

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Due to the COVID-19 health crisis, a tele-inspection was conducted. Licensing Program Analyst (LPA) Van met via Facetime with the Licensee, Peter Kozaczuk, and Licensee's helper, Adriana Ruiz Sanchez. There were six children being care for by the Licensee and two helpers. The purpose of the tele-inspection today was to conclude the complaint investigation and deliver the findings.

During the investigation, all relevant information was obtained and reviewed; all parties involved were contacted and interviewed. Based on the interview, the Licensee admitted that due to the COVID-19 pandemic, the Licensee did not allow parents to enter the facility as a precautionary safety measure. The Licensee failed to accommodate parents under Title 22 Regulations regarding Parental and Authorized Representative's Rights. As a result, the preponderance of evidence standard has been met. Therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 12, Chapter 1), is being cited on the attached LIC 9099D.")

This report was discussed with the Licensee and helper. The report was emailed to the Licensee.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon Van	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 05-CC-20210503130155

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: KOZACZUK, PETER	FACILITY NUMBER: 414002986
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/27/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/11/2021 Section Cited CCR 102419(a)(1)	1 2 3 4 5 6 7	102419 Admission Procedures and Parental and Authorized Representative's Rights. (a)The Licensee shall inform parents or authorized representatives of children in care of their rights, which include, but are not limited to, the following:(1)To enter and inspect the family child care home in accordance with Health and Safety Code Section 1596.857.	1 2 3 4 5 6 7	The facility shall work with parents to develop a structural plan that incorporates COVID-19 protocol to ensure precautionary safety measures are followed and reasonable accommodation, so all parties feel comfortable when parents enter and inspect the facility during childcare hours.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by records review and interviews; the Licensee failed to allow parents to enter and inspect the Family Child Care Home. This This poses a potential health and safety risk to childen in care.	8 9 10 11 12 13 14	The plan should include compliance with State and Local Public Health COVID-19 guidelines. The facility shall also submit this plan to LPA via email by the due date of 6/15/2021.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon Van	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021

LIC9099 (FAS) - (06/04)

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