214200048-8-9-2024-05-CC-JTSE-D7YQRE-20240809122347

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 214200048
Report Date: 08/09/2024
Date Signed: 08/09/2024 12:43:17 PM

Document Has Been Signed on 08/09/2024 12:43 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 CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	PAULSEN, NICOLE		FACILITY NUMBER:	214200048
ADMINISTRATOR/ DIRECTOR:	PAULSEN, NICOLE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(415) 302-3890
CITY:	MILL VALLEY	STATE: CA	ZIP CODE:	94941
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 13	DATE:	08/09/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:10 AM
MET WITH:	Adrian Cronin		TIME VISIT/ INSPECTION COMPLETED:	12:40 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	On 8/9/2024, at approximately 9:10AM, Licensing Program Analyst (LPA) Jonathan Tse conducted an unannounced annual visit at the facility. LPA met with staff member Adrian Cronin (S1) and explained the purpose of the visit. Licensee Nicole Paulsen was not present during today’s visit. Present during today’s visit was S1, two other helpers, 11 preschool age children, and two infants. Daycare Areas: Kitchen, Living Room, Playroom, Bedroom #1, Bedroom #2, Bathroom, and Backyard. Off-limits Areas: Entirety of the Upper Level, Laundry Room. LPA and S1 inspected the facility for any health or safety hazards. LPA observed the facility to be equipped with fully charged fire extinguishers that are size 2A10BC. During the visit, the carbon monoxide detectors in the facility were demonstrated to be operational. Electrical outlets are childproof and do not require covers. There are no fireplaces in the daycare areas. LPA observed all stairs to be barricaded and inaccessible to children in care. Poisons, cleaning detergents, and other chemicals are stored inaccessible to children in care. LPA advised that drawers that are intended to be inaccessible to children should be secured with a childproof latch or lock. S1 stated that they understood. LPA observed age-appropriate toys and learning materials to be present in the facility. Furniture was observed to be age-appropriate and free of rough or sharp edges. Children nap on mats that are provided by the facility. Per S1, the facility provides all bedding and blankets for children in care. LPA observed there to be at least one crib for each infant present. LPA discussed safe sleep requirements with S1. LPA informed S1 that sleep sacks are considered swaddling devices and are no longer allowed in Family Child Care Homes. S1 stated that they understood. Per S1, the facility provides lunch and AM/PM snacks for children in care. Continued on Page Two

SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024

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 08/09/2024 12:43 PM - It Cannot Be Edited

Created By: Jonathan Tse On 08/09/2024 at 11:08 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: PAULSEN, NICOLE	FACILITY NUMBER: 214200048
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

102416.5(d)(2)

Staffing Ratio and Capacity

(d) For a Large Family Child Care Home, the maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home, including children under age 10 who reside at the licensee's home and the assistant provider's children under age 10, shall be either: (2) More than twelve and up to fourteen children only if the criteria in Section 1597.465 of the Health and Safety Code are met. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above by having a 13th child in care while not meeting the criteria of Section 1597.465 of the Health and Safety Code which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/12/2024
	Plan of Correction
1 2 3 4	S1 stated that C13 was only present for today and would be leaving the facility. LPA informed S1 that a follow-up visit would be conducted to confirm compliance with staffing and ratio requirements.

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:

Ali Zebila

LICENSING EVALUATOR NAME:

Jonathan Tse

LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024

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 CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PAULSEN, NICOLE	FACILITY NUMBER: 214200048
	VISIT DATE: 08/09/2024

NARRATIVE

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Upon inspection of the Playroom, LPA observed that there were 13 children in care. LPA discussed staffing and ratio requirements with S1. S1 stated that the 13^th child (C13) was only present during today’s visit due to a request from C13’s parents. S1 stated that C13 would be leaving the facility by noon. LPA informed S1 that a Type A deficiency would be cited during today’s visit and that a follow-up visit would be conducted to confirm compliance. S1 stated that they understood.

LPA observed the Backyard to be free of debris and other loose articles. The facility shares the Backyard with facility #214005300. S1 stated that they do not use the Backyard at the same time. LPA advised that children from both programs shall not co-mingle. S1 stated that they understood. LPA observed there to be umbrellas to provide shade. Children have access to drinking water when they are outside. The Backyard is enclosed by a fence that is at least four feet high. There are age-appropriate play structures present that are cushioned with resilient padding. There are no pools or other similar bodies of water present in the facility.

LPA reviewed four staff files, 13 children’s files, and facility records. Licensee’s First Aid/CPR is current and expires 4/2026. Licensee’s Mandated Reporter Training expires 1/2025. LPA observed there to be at least one staff member present during today’s visit with current Pediatric First Aid/CPR training. LPA advised S1 to maintain all staff records on file at the facility. S1 stated that they understood. LIC126 (Entrance Checklist) was provided during the visit for S1’s reference.

LPA observed all children’s files to be complete. Infant sleeping logs are maintained digitally. LPA advised that the facility should maintain a record of the logs so that past sleeping logs will be available for review. S1 stated that they understood. LPA observed all required postings to be posted and accessible for review immediately upon entry to the facility. The facility last conducted an emergency drill on 8/5/2024. Emergency drills are logged and documented digitally.

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.
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SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024

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 CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PAULSEN, NICOLE	FACILITY NUMBER: 214200048
	VISIT DATE: 08/09/2024

NARRATIVE

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Facility representative 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.

LPA discussed the safe sleep regulations with the facility representative 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 facility representative 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.

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/.

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

Continued on Page Four

SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024

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 CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PAULSEN, NICOLE	FACILITY NUMBER: 214200048
	VISIT DATE: 08/09/2024

NARRATIVE

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See LIC809-D for Type A deficiency cited today regarding capacity requirements. A plan of correction was discussed and agreed upon by both LPA and S1. See LIC9102-TV for technical violations issued today. See LIC9102-TA for technical assistance given today. Appeal rights were provided and explained to S1.

LPA Tse informed facility representative Adrian Cronin that this report dated 8/9/2024 documents one Type A citation which shall be posted for 30 consecutive days as there is immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Tse informed the facility representative to provide a copy of this licensing report dated 8/9/2024 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the facility representative, Adrian Cronin.

SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024

LIC809 (FAS) - (06/04)

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