414004492-10-18-2019-05-CC-MROZ-BH3N5X-20191018101016

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414004492
Report Date: 10/18/2019
Date Signed: 10/18/2019 10:10:23 AM

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:	OSBORNE, LILLIANE M.		FACILITY NUMBER:	414004492
ADMINISTRATOR:	OSBORNE, LILLIANE M.		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(650) 393-4753
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94403
CAPACITY:	14	CENSUS: 8	DATE:	10/18/2019
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	08:25 AM
MET WITH:	Lilliane Osborne		TIME COMPLETED:	10:25 AM

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 made an unannounced Case Management visit to follow up on an incident reported to CCLD office by phone on September 19, 2019 regarding a child sustaining an injury while playing outside in the backyard. LPA met with Licensee Lilliane Osborne and explained purpose of visit. LPA toured the outdoor play area with Licensee and observed the play structures in the backyard which include a small slide play structure and a dome climber. Licensee showed LPA where the child had been playing when the injury occurred. Licensee explained on the afternoon of September 18, 2019, Child C1 had been climbing and playing on the dome climber and had been sitting on a bar of the dome climber (which was about a foot above the grass) when C1 asked Licensee to look in C1's direction. C1 had been asking Licensee to look as C1 played on structure throughout the afternoon. As Licensee looked at C1, C1's hands slipped off the bars of the climber and C1 fell back onto the grass area in the inside space of the dome climber. Licensee went to soothe C1 as C1 started to cry. Licensee brought C1 inside to ice C1's arm. Licensee checked C1's arm and asked C1 to lift their arm up and make a fist. C1 stated they could not do either and started to cry. C1's father arrived about five minutes later and Licensee suggested for C1 to be seen by a physician because she thought C1's injury may be serious. Licensee received an email update later that night from C1's parents that C1 had sustained a broken arm near the elbow. Licensee stated that one of C1's favorite activities is climbing and playing on the dome climber for long periods of time each day and that C1's parents have told Licensee that C1 loves to climb everywhere. (Continued on second page)

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) -26-8800
LICENSING EVALUATOR NAME: Marie Rodriguez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2019

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: OSBORNE, LILLIANE M.	FACILITY NUMBER: 414004492
	VISIT DATE: 10/18/2019

NARRATIVE

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(Continued from first page)

Licensee explained normally during the children's afternoon outdoor play, one of her teaching assistants is inside the home cleaning up while the Licensee and her other teaching assistant are outside supervising the children as the children play and help clean up the outdoor area with them. Licensee stated she has spoken to her teaching assistants about changing the afternoon activities prior to parent pickup to ensure all staff are available in the backyard while children play outdoors instead. Children will end the day sitting at the table doing a group activity like play doh or magnetic connect blocks when children are picked up by parents. Licensee has also spoken to staff about having safety talks with each new child about the dome climber and the parameters for children to play on it.

No deficiencies cited today.

LPA informed Licensee of San Mateo FCCH Stakeholder's Meeting that will be held on November 2, 2019 and provided her with an invitation to attend.

Report was reviewed and discussed with Licensee Lilliane Osborne. 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) -26-8800
LICENSING EVALUATOR NAME: Marie Rodriguez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2019

LIC809 (FAS) - (06/04)

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