414002986-4-23-2024-05-CC-MZAA-D4LQRP-20240423122415

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414002986
Report Date: 04/23/2024
Date Signed: 04/23/2024 12:24:20 PM

Document Has Been Signed on 04/23/2024 12:24 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:	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: 11	DATE:	04/23/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Licensee, Peter Kozaczuk		TIME COMPLETED:	12:45 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 23, 2024 at approximately 9:00am, Licensing Program Analyst’s (LPAs) Zaragoza and Quimbo, conducted an unannounced, annual inspection. LPAs were greeted and granted access by licensee’s spouse, Lilian Kozaczuk. Per spouse, licensee was in church and will arrive soon. At the entrance spouse was explained the purpose of the inspection. Present during LPA's visit included Licensee’s spouse, 2 staff, and 11 children (2 infants and 9 preschool age). Facility is operating within capacity limits and ratio on this date. Hours of operation are Monday through Friday. 8:00am to 5:00pm. Entrance to the facility is through side gate. Licensee lives in the multi-level home with their spouse. All adults living in the home and staff present, have fingerprint clearance on file. The DAY CARE AREAS are located on the first level of the home, that includes the Bedroom #1 (napping room), Bedroom #2 (not currently in use), Garage/ Playroom, Family Room, bathroom #1, side, and backyard. The OFF LIMIT AREAS are the entire second level of home, guest house in backyard and patio in backyard. Stairs in the backyard and stair to the main day care area are made inaccessible with child safety gates. LPAs toured day care areas of home with licensee’s spouse. LPAs observed home to be in good repair with proper temperature and ventilation. Home is equipped with a variety of toys and materials that were observed to be in good condition. LPAs observed electrical outlets to be made inaccessible with child safety covers. Cleaning supplies, poisons and hazardous materials are stored in home's high shelves and/or locked behind child safety locked cabinets. At approximately 9:40am licensee Peter Kozaczuk arrived to family. Home is equipped with multiple fully charged fire extinguishers and multiple smoke and carbon monoxide detectors. Smoke and carbon monoxide detectors were tested during visit and was observed to be in working condition. Napping room (bedroom#1) was observed to be equipped with cribs for napping children. Cribs were observed to be free of loose articles, bumper pads and pillows. LPAs observed cribs to have mattresses with tight fitting sheets. Sleeping logs for napping infants are maintained and includes the 15 minute time check of when infant was last checked on and sleeping position. (Continue Report on Page 2...)

SUPERVISOR'S NAME: Marie Rodriguez	TELEPHONE: (650) 266-8827
LICENSING EVALUATOR NAME: Melissa Zaragoza	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

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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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: KOZACZUK, PETER	FACILITY NUMBER: 414002986
	VISIT DATE: 04/23/2024

NARRATIVE

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Bathroom was observed to be in proper working condition. There is appropriate sanitation and toileting equipment for children in care. LPAs observed children’s diapers and wipes in bathroom to be properly labeled with each child’s individual names. Per licensee’s spouse, children’s families provide diapers and wipes for enrolled children.

Children eat in dining area. A food service is provided to children that includes breakfast, lunch and 2 snacks. LPAs observed eating area to be clean and equipped with appropriate dining furniture. Children’s dietary restrictions and allergies are posted in kitchen. Disposable cups and plates are utilized. LPAs observed knives to be made inaccessible.

Outdoor area is entirely enclosed and fenced. Outdoor area includes a variety of toys and equipment that were in good condition. Stairs in backyard were made inaccessible with a child safety gate. Garbage bins in backyard are also made inaccessible to children. There is a grill in the backyard, per licensee’s spouse, gas to grill is turned off. LPAs did not observe any pools, spas or bodies of water on site.

LPAs reviewed 6 random children's records which were complete. Children's files have record of identification emergency information. LPAs reviewed licensee, licensee's spouse's and all staff whom were present’s records, which were complete. Licensee and spouse have a current CPR/First Aid certifications and current Mandated Reporter certifications. Licensee's CPR/First Aid certification and Mandated Reporter certifications will expire 08/2025. All staff present have their required immunizations available for review.

Emergency disaster drills are conducted and are appropriately documented. Last disaster drill was conducted 12/2023. LPAs observed licensing documentation to be properly posted, made available for review. Facility maintains a childcare roster that was also made available for review. Per licensee, there are no weapons or firearms in the 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.

(Continue Report on Page 3...)

SUPERVISOR'S NAME: Marie Rodriguez	TELEPHONE: (650) 266-8827
LICENSING EVALUATOR NAME: Melissa Zaragoza	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: KOZACZUK, PETER	FACILITY NUMBER: 414002986
	VISIT DATE: 04/23/2024

NARRATIVE

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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 athttps://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.

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, the licensee, Peter Kozaczuk, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

No deficiencies were issued during today's visit. A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee, Peter Kozaczuk.

SUPERVISOR'S NAME: Marie Rodriguez	TELEPHONE: (650) 266-8827
LICENSING EVALUATOR NAME: Melissa Zaragoza	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

LIC809 (FAS) - (06/04)

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