414004079-1-30-2020-05-CC-MROZ-BLBUUZ-20200130145423

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414004079
Report Date: 01/30/2020
Date Signed: 01/30/2020 02:54:29 PM

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:	DEVLIN, JENNIFER M. & KURT R.		FACILITY NUMBER:	414004079
ADMINISTRATOR:	DEVLIN, JENNIFER M. & KURT		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(650) 393-5745
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94401
CAPACITY:	14	CENSUS: 12	DATE:	01/30/2020
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Jennifer Devlin		TIME COMPLETED:	03:10 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	Licensing Program Analyst (LPA) Marie Rodriguez conducted an unannounced Annual Random inspection. LPA met with Licensee Jennifer Devlin and explained purpose of inspection. Home is a singe story house with 3 bedrooms and 2 bathrooms. Licensee lives in home with her husband and two children. Present in home were the Licensee, her school aged daughter, a helper, and 11 children (3 infants and 8 preschool age). Licensee is operating within capacity requirements on this day. All adults living or working in the home have a criminal record clearance on file. Hours of operation are Monday to Thursday from 8:00am to 5:30pm and Friday from 8:00am to 5:00pm. Day Care Areas: Living room, kitchen, dining room, family room/playroom, bedroom #1 (sleeping only), bedroom #2 (sleeping only), and bathroom. Off Limit Areas: Master bedroom, master bathroom, garage, and backyard. LPA toured day care areas of home with Licensee. LPA observed home to be clean and in good repair with proper temperature and ventilation. Per Licensee, there are no weapons or firearms in the home. There is a variety of age appropriate toys and equipment in the home which are in good condition. All cleaning supplies, poisons, and other chemicals are stored inaccessible to children. There are multiple working smoke detectors and carbon monoxide detectors throughout the home, a fully charged fire extinguisher, and a working telephone. Phone number listed for Licensee is current. Eleven children records reviewed were complete. All children have a record of emergency identification information on file. Licensee record was reviewed and complete. Licensee's Pediatric First Aid/CPR certificate expires January 2021. Last emergency drill was conducted on September 9, 2019. Emergency drills are conducted at least once every six months and are properly logged. (Continued on second page)

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Marie Rodriguez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2020

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: DEVLIN, JENNIFER M. & KURT R.	FACILITY NUMBER: 414004079
	VISIT DATE: 01/30/2020

NARRATIVE

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(Continued from first page)

Incidental Medical Services (IMS) was discussed. Licensee has one child in care who needs services at this time. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding Americans with Disabilities Act (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: www.ada.gov/childqanda.htm.

During inspection,

Licensee was given information regarding Safe Sleep Practices, Technical Support Program, and Lead Poisoning Facts Flyer.
Licensee was reminded, as of September 1, 2016, all Staff and Volunteers must provide proof of immunization against pertussis, measles, and influenza, or qualifies for an exemption, pursuant to Health and Safety code 1596.7995 and 1597.622.
Licensee was reminded about Mandated Reporter training available on CCLD website. Training must be completed every 2 years. Training can be taken online at www.mandatedreporterca.com.
Licensee was reminded about the Provider Information Notices (PINs) on CCLD website.
Licensee was advised for any additional questions to contact CCLD office, Monday to Friday, 8:00 am - 5:00 pm, (650) 266-8800 or 1 (844) 538-8766. Website: www.cdss.ca.gov.

No deficiencies cited today.

This report was reviewed and discussed with Licensee Jennifer Devlin . A copy of report was provided.
Notice of site visit was observed being posted and shall remain posted for 30 days.

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Marie Rodriguez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2020

LIC809 (FAS) - (06/04)

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