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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380505746
Report Date: 04/24/2025
Date Signed: 04/24/2025 02:03:57 PM

Document Has Been Signed on 04/24/2025 02:03 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:JEFFERSON, GLADYS & KARENFACILITY NUMBER:
380505746
ADMINISTRATOR/
DIRECTOR:		JEFFERSON, GLADYSFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 752-3978
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94118
CAPACITY: 12TOTAL ENROLLED CHILDREN: 3CENSUS: 1DATE:
04/24/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:28 PM
MET WITH:Karen and Gladys JeffersonTIME VISIT/
INSPECTION COMPLETED:
02:20 PM
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On April 24, 2025, Licensing Program Analyst (LPA) Leong conducted an unannounced annual visit. LPA met with Licensees Karen Jefferson (S1) and Glayds Jefferson (S2) and explained the purpose of the visit. LPA observed a cat in the facility, and according to S1, the cat is fully vaccinated.

One child (infant), S1 and S2, were present at today's visit. Both S1 and S2 have a criminal record clearance from the California Department of Social Services (CDSS).

LPA found that all necessary documents were displayed on the white board. This includes the facility license, Notifications of Parents’ Rights, and Earthquake Preparedness Checklist.

The most recent emergency disaster drill took place on January 3, 2024, and the LPA observed that it was documented. LPA reviewed the emergency disaster drill log and found the facility did not meet the every six-month requirement for conducing emergency disaster drills. Therefore, the facility will receive a technical violation.

The daycare areas consist of the living room, dining room, and bathroom in the lower level.

The off-limit areas consist of the entire upper level and backyard. Both S1 and S2 understand that off-limits areas may not be used for childcare during business hours.

LPA inspected the indoor areas to identify health and safety hazards. The home has a fully functional fire extinguisher, a first aid kit, and a combo carbon monoxide/smoke detector.

Disinfectants, cleaning solutions, poisons, and other hazardous items were stored in areas inaccessible to children. The bathroom was fully operational, and equipped with sanitation products.

See Page 2

NAME OF LICENSING PROGRAM MANAGER: Garfield Leung
NAME OF LICENSING PROGRAM ANALYST: Hanson Leong
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: JEFFERSON, GLADYS & KAREN
FACILITY NUMBER: 380505746
VISIT DATE: 04/24/2025
NARRATIVE
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The daycare areas have toys, furniture, and learning materials that are suitable for the children's ages. The fireplace was observed to be surrounded by a gate. A child safety gate was observed at the stairs leading to the upper level.

S1 said that there were no firearms or weapons on the property.

LPA did not find any pools, spas, or other bodies of water on the property.

The facility serves lunch and snacks to the children. The children’s parent may also bring lunch and snacks for their children. S1 reported that none of the children enrolled have allergies listed in their records.

LPA reviewed one child's file and confirmed that the child had a complete record. The children's files contain records of emergency identification information and necessary immunizations. LPA reviewed the fifteen-minute sleep check records for the one child under two years old and found them complete.

LPA reviewed two staff (S1 and S2) files and confirmed that both Pediatric First Aid/CPR and Mandated Reporter Training certifications are current.

Licensee 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/.

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NAME OF LICENSING PROGRAM MANAGER: Garfield Leung
NAME OF LICENSING PROGRAM ANALYST: Hanson Leong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: JEFFERSON, GLADYS & KAREN
FACILITY NUMBER: 380505746
VISIT DATE: 04/24/2025
NARRATIVE
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LPA discussed the safe sleep regulations with licensee 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 licensee 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.

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

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.

TECHNICAL VIOLATION: Violations of the Health and Safety Code (HSC), regulations (CCR), or interim licensing standards (ILS) that do not pose a health, safety or personal rights risk.

No deficiencies were issued during today’s visit.

A Notice of Site Visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Licensee, Karen Jefferson.

NAME OF LICENSING PROGRAM MANAGER: Garfield Leung
NAME OF LICENSING PROGRAM ANALYST: Hanson Leong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC809 (FAS) - (06/04)
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