414002986-10-28-2021-05-CC-GLEG-C8F2GV-20211103172347

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 414002986
Report Date: 10/28/2021
Date Signed: 10/28/2021 11:56:41 AM

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
09/16/2021 and conducted by Evaluator Brendon Van

PUBLIC

COMPLAINT CONTROL NUMBER: 05-CC-20210916101021

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: 7	DATE:	10/28/2021
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Peter Kozaczuk		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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-Unassociated staff caring and supervising children while in care.

INVESTIGATION FINDINGS:

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On October 28, 2021, Licensing Program Analyst(LPA) Van conducted a subsequent complaint inspection to deliver the above allegation findings. LPA met with the Licensee, Peter Kozaczuk. The purpose of the inspection was explained, and the Licensee granted LPA access to the home. There were seven children in care with the Licensee and two helpers.
As part of the complaint investigation, interviews were conducted, and pertinent information was obtained and reviewed. Based on the information available, the Licensee's spouse, Lilian Kozaczuk, resides at home and frequently provides care to childcare children. Although Lilian Kozaczuk has a fingerprint clearance, her fingerprint clearance was not associated with Mr. Kozaczuk's facility. 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 3), Type B is cited on the attached LIC 9099D.")
The report was reviewed and signed by the Licensee, Peter Kozaczuk. An exit interview was conducted, and rights to comment were discussed with the Licensee. Today's report, 10/28/2021, and notice of site visit will be sent to the Licensee email by the close of business on 10/28/21. Confirmation of receipt is required, and this report must be available in the facility for public review. Notice of site visit shall be posted for 30 days from today's visit.

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: 10/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021

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-20210916101021

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: 10/28/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/11/2021 Section Cited CCR 102370(d)(2)	1 2 3 4 5 6 7	102370 Criminal Record Clearance (d)All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility:(2)Request a transfer of a criminal record clearance as specified in Section 102370(j)	1 2 3 4 5 6 7	Licensee shall ensure that all adults have fingerprint clearance and associated prior to working, residing, or volunteering in a licensed home. Licensee's stated he would submit all requirements for Lilian Kozaczuk, including a Criminal Background Clearance Transfer Request to Licensing no later than November 11, 2021.
	8 9 10 11 12 13 14	This requirement was not met, as evidenced by interviews and records review. The Licensee spouse resides at home and provided care to daycare children and did not have fingerprint clearance associated with the facility, and this poses a potential safety risk to the children in care.	8 9 10 11 12 13 14
	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: 10/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021

LIC9099 (FAS) - (06/04)

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