214005345-10-4-2023-05-CC-HLEG-CWAQP4-20231004122006

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 214005345
Report Date: 10/04/2023
Date Signed: 10/04/2023 12:20:39 PM

Document Has Been Signed on 10/04/2023 12:20 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 CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	MC COY, KIYOKO		FACILITY NUMBER:	214005345
ADMINISTRATOR:	MC COY, KIYOKO		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(415) 342-9482
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 5	DATE:	10/04/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Kiyoko McCoy		TIME COMPLETED:	12:25 PM

NARRATIVE

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On 10/4/2023, Licensing Program Analyst (LPA) Hanson Leong, made an unannounced annual visit to the Family Child Care Home listed above. The LPA was granted entry by the Licensee, Kiyoko McCoy. The LPA explained the purpose of the visit to Ms. McCoy. The LPA observed Ms. McCoy and her assistant supervising five preschool aged children. During today’s visit, Ms. McCoy’s husband was present in the home. All individuals listed on the facility’s roster have been granted permission to work or be present in a childcare facility. The facility is operating within its capacity and in accordance with the required ratio of staff to children.

Day-care Areas: Front patio, Living Room, Bathroom #1, and Backyard.

Off Limit Areas: Bedroom #1, Bedroom #2, Bedroom #3, Bathroom #2, Garage and Gated Path (Pass through only).

The LPA and Ms. McCoy both performed careful inspections of the daycare facility to look for any potential health and safety hazards. Toys and equipment that are suitable for children of the proper age range are provided at the daycare. The building has sufficient lighting and ventilation, and it is free of any defects or conditions that put children at risk. The facility is equipped with a first aid kit that is completely loaded with everything that is required for the treatment of injuries. The daycare facility is equipped with a smoke detector, a carbon monoxide detector, and a fire extinguisher that is always ready for use. Every garbage can and power outlet has been covered. Products for cleaning and washing, detergents, and any other materials that could put children in danger are stored out of the children’s reach. The LPA did not find any walkers, bouncers, or other comparable objects during today’s inspection. According to Ms. McCoy, there are reportedly no firearms or other weapons on the premises. The LPA found that the facility did have a fish pond, which is inaccessible to the children.

The LPA observed that the facility had posted all the required forms, including the facility license, Notification of Parental Rights, Earthquake Preparedness Checklist, and Notification of Personal Rights. The Licensee is aware that smoking is not permitted in a family childcare facility.

***See Page 2***

SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Hanson Leong
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

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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Document Has Been Signed on 10/04/2023 12:20 PM - It Cannot Be Edited

Created By: Hanson Leong On 10/04/2023 at 11:34 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MC COY, KIYOKO	FACILITY NUMBER: 214005345
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102416(c)

Personnel Requirements

(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to children in care.
	POC Due Date: 11/04/2023
	Plan of Correction
1 2 3 4	Licensee will be required to submit a new CPR and First Aid card to the department by the above due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Daniel J Oquendo

LICENSING EVALUATOR NAME:

Hanson Leong

LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

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 CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MC COY, KIYOKO	FACILITY NUMBER: 214005345
	VISIT DATE: 10/04/2023

NARRATIVE

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Continued, Page 2
The LPA reviewed the files for the five children, The LPA observed that the five children's files contain immunization information, as well as the names, addresses, and phone numbers of each child's authorized representative.

The LPA reviewed the files of Ms. McCoy and her assistant. The LPA observed that both staff members are not current with their Pediatric First Aid/CPR certification. (Refer to LIC 809D for citation) The LPA also observed that both staff members are not current with their Mandated Reporter training certification. (Technical violated was issued)

The LPA reviewed the facility's emergency drill log. According to Ms. McCoy, the facility’s emergency drills have not been carried out because the facility recently reopened on 9/6/2023. The LPA reminded Ms. McCoy to complete the emergency drills every six months.

Ms. McCoy 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.

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/.

LPA discussed the safe sleep regulations with Ms. McCoy and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed McCoy 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.
***See Page 3 ***

SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Hanson Leong
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MC COY, KIYOKO	FACILITY NUMBER: 214005345
	VISIT DATE: 10/04/2023

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

On 10/3/2023, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-carelicensing/subscribe and select the Child Care option to receive email communication.

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.

Please refer to LIC 809D for today’s citation.

A copy of today’s report and the facility’s appeal rights were given to Kiyoko McCoy. The Notice of Site Visit was given to Kiyoko McCoy and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Exit interview conducted and report was reviewed with Kiyoko McCoy.

SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Hanson Leong
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

LIC809 (FAS) - (06/04)

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