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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004529
Report Date: 06/29/2021
Date Signed: 06/30/2021 01:42:39 PM

Document Has Been Signed on 06/30/2021 01:42 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:BURRELL, AMINA M.FACILITY NUMBER:
414004529
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 7DATE:
06/29/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Amina BurrellTIME COMPLETED:
02:00 PM
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Licensing Program Analyst's (LPAs), Tapia-Mandujano and Yee conducted an unannounced inspection for increase of capacity today and met with licensee, Amina Burrell for her request to increase from a Small to a Large Family Child Care. Fire Clearance has been granted by Menlo Park Fire Department on 6/21/21.

LPAs and licensee inspected entire home for Health and Safety Hazards. Licensee rents home, which is a three (3) bedroom, one (1) bathroom, single level house. Licensee lives with Husband and 2 minor children. Licensee has a Chicken coop in the Backyard, which is properly barricaded. Daycare area is: Living Room, Den, Bathroom #1, Bedroom #1, Bedroom #2, Bedroom #3, Kitchen, and Backyard. OFF limit areas: Garage. All off limit areas are properly barricaded.

Home has multiple working smoke detectors, a carbon monoxide detector, a working telephone, and a fully charged Fire Extinguisher. First Aid Kit is fully stocked and accessible. All harmful and sharp objects are made inaccessible from children in care. Licensee states there are no guns or weapons in the home. The home is clean and orderly with sufficient lighting and ventilation. Licensee states she will conduct an emergency drill once every six months and log drills. Home has age appropriate toys and equipment available for the children in care. Licensee states discipline policy is redirection. Licensee CPR & First Aid has expired on 1/2021. CPR Waiver is on file for licensee as of 6/23/21 (PIN 21-07-CCP: Child Care Covid-19 Waiver Attestation Form). Licensee has registered to attend a CPR & First Aid Class July 19,20, 21,24 (2 hours each day, total 8 hours). Postings were posted near main door. Licensee is reminded of NO walker, exersaucers, jumpers, bouncers and any similar items to be used for children in care and shall be made inaccessible.

Continued on LIC 809C...
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2021
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: BURRELL, AMINA M.
FACILITY NUMBER: 414004529
VISIT DATE: 06/29/2021
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Continued from LIC 809...

LPAs explained and provided a copy of Tittle 22 regulations for capacity of a Small and Large Family Child Care Home. Capacity worksheet was also provided.

This report is discussed and explained to the applicant. Records to be Maintain in the facility was previously explained to use for all children in care. Mandatory Posting Requirements: License, Emergency Disaster Plan, and Notification of Parents Rights Poster.

Prior to recommended for licensure, licensee must receive management approval.

Copy of this report was emailed to the licensee. Signed copy of this report will be kept in the facility file and made available for public review. Desk Duty is available Monday through Friday between 8:00 AM - 5:00 PM at (650) 266-8800. Website for forms and Regulations: www.cdss.ca.gov
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021
LIC809 (FAS) - (06/04)
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