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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004284
Report Date: 01/10/2020
Date Signed: 01/10/2020 12:18:59 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:OLSEN-DONIO,ROSSANNA M.FACILITY NUMBER:
414004284
ADMINISTRATOR:OLSEN-DONIO, ROSSANNA M.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 994-2540
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:14CENSUS: 11DATE:
01/10/2020
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Rossanna Olsen-Donio, Karine DescampTIME COMPLETED:
12:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Andrea Medlin met with Licensee, and helpers, for this annual licensing visit today. Purpose of the visit explained. Days and hours of operation: Monday-Friday 8:00AM-5:30PM. There are 11 preschool aged children present. Licensee states she, husband, and two adult daughters reside in the home; criminal record clearance is on file for all adults. Licensee reminded once a person turns 18 years of age, and if living or working in the home, criminal record clearance is required. Physical plant toured to inspect for health and safety hazards in the licensed areas. Outdoor space inspected for health and safety hazards; outdoor play area is completely fenced. The daycare has a fully charged fire extinguisher that meets the minimum requirements, and smoke detectors, and a carbon monoxide (CO) detector in the daycare. First aid supplies are available. Detergents, cleaning compounds, medications, and other items which could pose a danger to children is stored inaccessible to children. The daycare area is kept clean and orderly and has adequate heating and ventilation for safety and comfort. Per Licensee, there are no firearms or weapons in the home. No spas, swimming pools, hot tubs, fish ponds, or similar bodies of water are present. Variety of age appropriate toys and materials is observed in the daycare. A sick child would be separated from the group and wait for parent to pick up. Licensee has current Pediatric First Aid and CPR certification (exp 11/2020). Children's files reviewed. In the children's files reviewed, all have Parent's Rights (LIC 995A) form and current immunization records. All the required licensing forms are posted in the daycare area. S1 does not have immunizations; S2 does not have the pertussis immunization. Licensee does not have verification of the mandated child abuse reporter training as compliant AB1207.

(Continued on next page 809-C and 809-D)
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Andrea MedlinTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
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: OLSEN-DONIO,ROSSANNA M.
FACILITY NUMBER: 414004284
VISIT DATE: 01/10/2020
NARRATIVE
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Incidental Medical Services (IMS) policy discussed. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA is 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: http://www.ada.gov/childqanda.htm. LPA reviewed with Licensee the Mandated Child Abuse Reporting training as compliant with AB 1207. As of January 1, 2018 all child care staff are required to complete Mandated Child Abuse Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com.

The deficiencies cited on the following page are in violation of the California Code of Regulations, Title 22, Division 12, Chapter 1.

This report is reviewed with Licensee and a copy of this report must be made available for public review upon request.

Notice of site visit posted and shall remain posted for 30 days.
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Andrea MedlinTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2020
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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: OLSEN-DONIO,ROSSANNA M.
FACILITY NUMBER: 414004284
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/10/2020
Section Cited

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On and after January 1, 2018, a person who becomes an administrator or employee of a licensed child day care facility shall complete the mandated reporter training pursuant to paragraphs
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within the first 90 days of employment. This requirement is not met as evidence Licensee does not have the mandated child abuse training. This is a potential health and safety hazard.
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For access to the training:

www.mandatedreporter.ca.com

Send proof of correction to the licensing office by 2/10/2020.
Type B
02/10/2020
Section Cited

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Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles.
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This requirement is not met as evidence S1 does not have verification of immunizations and S2 does not have the pertussis (whooping cough) immunization. This is a potential health and safety hazard
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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 LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Andrea MedlinTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2020
LIC809 (FAS) - (06/04)
Page: 3 of 3