414002986-4-27-2022-05-CC-BVAN-CDVVW5-20220427164721

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414002986
Report Date: 04/27/2022
Date Signed: 04/27/2022 04:48:13 PM

Document Has Been Signed on 04/27/2022 04:48 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:	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: 12	DATE:	04/27/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Peter Kozaczuk		TIME COMPLETED:	05:00 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 April 27, 2022, Licensing Program Analyst (LPA), Van, conducted an unannounced required annual inspection and met with Licensee Peter Kozaczuk. The purpose of the inspection was explained and granted entry to the home by the Licensee. Present today are 12 children (4 infants and 8 preschoolers) with the Licensee and two helpers. The facility complies with the license capacity and limitations today. All adults living or working in the home have a criminal background clearance on file. The Licensee owns this single-family home consisting of two floors with 5 bedrooms and 3 ½ bathrooms. Daycare areas Garage/ Playroom, Family Room, Living Room, Bedroom #1, bathroom #1, side and backyard. Off Limit areas are Bedroom #2, Kitchen and Dining Room, Entire Upstairs Level. Per Licensee, when a child shows signs of illness, the Licensee will separate and have the child waiting in the playroom/garage while contacting the parent to pick them up. The Days and operation hours are 8:00 am – 5:00 pm, Monday – Friday. LPA toured and inspected inside and outdoor play areas with the Licensee for health and safety hazards. The daycare area is clean, orderly, and equipped with safe, age-appropriate toys, books, and play equipment. The home has adequate heating, lighting, and ventilation and is free from defects or conditions that endanger children in care. Children have cubbies for their belongings. Highchairs were observed clean and in good condition. LPA reminded the Licensee that high chairs are only used when feeding children. The home is equipped with a fully charged fire extinguisher, smoke and carbon monoxide detectors, and a working telephone. Fully stocked first aid supplies are available for children. All playpens are in good condition, and there are no toys or pillows inside. The mattress pads are the exact size and have a fitted sheet. Cots are provided to older children, and the older children's napping area is in the garage/playroom. All unused electrical outlets have a child-proof cover. Poisons, detergents, and cleaning compounds are made inaccessible to children. The backyard play structures are age-appropriate, in good condition, and free of loose parts. There are no bodies of water in the facility. Fencing and baby gates were observed at the bottom stairs leading to the backyard. The Licensee stated there were no firearms, weapons, or pets in the home, and no baby walkers, bouncers, or similar items in the daycare. Licensee understands that smoking is prohibited in family child care homes.

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon Van	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2022

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: KOZACZUK, PETER	FACILITY NUMBER: 414002986
	VISIT DATE: 04/27/2022

NARRATIVE

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Licensee states fire and Earthquake drills are conducted at least every six months. The last drill was conducted on January 13, 2022. The facility provides breakfast, lunch, and morning & afternoon snacks. During the inspection, LPA reviewed all records of the children present. The Licensee has complete records for children in care, including immunization records and Parents' Rights forms. LPA observed each child has a complete emergency information card with the child's full name, telephone number, and location of a parent or authorized representative to be contacted in an emergency. The name and telephone number of the child's physician and the parent's authorization for the Licensee to consent to emergency medical care. Licensee and helpers maintained their immunization records and had valid mandated reporter training. Pediatric CPR/First Aid Licensee and helpers are valid. Licensees posted all the required forms, such as facility License, Notification of Parent's Rights, Earthquake Preparedness checklist, and Notification of Personal Rights.
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.
LPA discussed the safe sleep regulations with the Licensees and discussed the Child Care Licensing Safe Sleep webpage https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed the 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.
The Licensee was reminded about the Provider Information Notices (PINs) on the CCLD website. Licensees were informed that as of September 1, 2016, a person may not be employed or volunteer at a child care facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662. LPA reviewed AB 1207 with the Licensees. As of January 1, 2018, all staff must complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com.

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon Van	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2022

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: KOZACZUK, PETER	FACILITY NUMBER: 414002986
	VISIT DATE: 04/27/2022

NARRATIVE

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LPA encouraged the Licensee to frequently visit our website at www.ccld.ca.gov for licensing regulations and new updates. The Licensee can also email at childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list for the updates.
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.
The report was reviewed and signed by Licensee Peter Kozaczuk. No deficiencies were observed in today's inspection. Today's report, 4/27/2022, and site visit notice will be sent to Peter Kozaczuk email by the close of business on 4/27/2022. Confirmation of receipt is required, and a site visit notice must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon Van	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2022

LIC809 (FAS) - (06/04)

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