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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214200048
Report Date: 08/20/2024
Date Signed: 08/20/2024 02:36:32 PM

Document Has Been Signed on 08/20/2024 02:36 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, NICOLEFACILITY NUMBER:
214200048
ADMINISTRATOR/
DIRECTOR:
PAULSEN, NICOLEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 302-3890
CITY:MILL VALLEYSTATE: CAZIP CODE:
94941
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 4DATE:
08/20/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:40 PM
MET WITH:Adrian CroninTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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On 8/20/2024, at approximately 1:40PM, Licensing Program Analysts Jonathan Tse and Diana Alvarado conducted an unannounced POC visit at the facility. LPAs met with facility representative Adrian Cronin (S1) and explained the purpose of the visit. Present during the visit was S1, one helper, two preschool age children, and two infants. The facility is in compliance with staffing and ratio requirements on this day.

On 8/9/2024, the facility was issued a Type A citation for operating over capacity with 13 children in care. LPA observed 13 children during their visit, and discussed a plan of correction with S1. S1 was informed of the requirement to provide parents with a copy of the report and an Acknowledgement of Receipt of Licensing Reports (LIC9224) to be kept in each child's file.

LPA also issued technical violations having to do with accessibility of drawers in the Kitchen and maintaining staff records. LPA provided technical assistance regarding safe sleep: infant sleep logs, use of sleep sacks, and mattresses specifically made for each crib being used. LPA discussed plans of correction with S1 on 8/9/2024.

On 8/20/2024, LPAs observed that there were four children in care. The facility has corrected the Type A deficiency issued on 8/9/2024. LPAs found that all children's files contained signed copies of LIC9224. The facility had posted the Notice of Site Visit and the report dated 8/9/2024 with the required postings in the entryway of the daycare areas. The Type A deficiency has been cleared and a letter of deficiencies cleared was printed and provided to S1 during the visit.

LPAs observed that the kitchen drawer was equipped with a childproof latch and was now fully inaccessible to children in care. Record review of staff records showed that all staff members now have a staff file maintained in the facility. LPAs observed that the facility kept infant sleeping logs on file and available for review. S1 showed LPAs mattresses that fit the cribs, and explained that the mattresses needed to be pulled to fit the cribs. LPAs observed that there sleep sacks present during the visit.
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SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2024
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 2
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: 08/20/2024
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No deficiencies were cited during today's visit on 8/20/2024. A notice of site visit was provided and must be posted for 30 days.

Exit interview was conducted and report was reviewed with facility representative, Adrian Cronin.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
LIC809 (FAS) - (06/04)
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