<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384000532
Report Date: 01/05/2022
Date Signed: 01/05/2022 11:24:18 AM

Document Has Been Signed on 01/05/2022 11:24 AM - 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:EHRLICH, EVELINAFACILITY NUMBER:
384000532
ADMINISTRATOR:EHRLICH, EVELINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 407-9257
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94122
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 11DATE:
01/05/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Evelina EhrlichTIME COMPLETED:
11:30 AM
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 January 05, 2021, Licensing Program Analyst (LPA) Winnie Ly conducted an unannounced complaint inspection and met with Licensee Evelina Ehrlich. This report is to cite a deficiency observed during today's Case Management inspection. Facility has 6 infants and 5 preschoolers in care.

At 10:40A.M., Based on reviewing of facility roster, facility has 2 more infants than license allowed. This poses immediate risk to the children in care. Type A deficiency is being cited based on LPA Winnie Ly’s observation and review of roster in accordance with the California Code of Regulations, Title 22, see LIC 809D.

Copy of this report and appeal rights were reviewed and discussed with licensee. Report will be emailed to Licensee whose signature on this form confirm have read the report.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Winnie Ly
LICENSING EVALUATOR SIGNATURE: DATE: 01/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/05/2022
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
Document Has Been Signed on 01/05/2022 11:24 AM - It Cannot Be Edited


Created By: Winnie Ly On 01/05/2022 at 10:52 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: EHRLICH, EVELINA
FACILITY NUMBER: 384000532

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/05/2022
Section Cited
CCR
102416.5(c)

1
2
3
4
5
6
7
Staffing Ratio and capacity:
Staffing Ratio and Capacity. The capacity specified on the license shall be the maximum number of children for whom care can be provided.
1
2
3
4
5
6
7
Licensee will work with parents to change the schedule of infants to part time in order to stay within ratio. This scheduling will be effective 01/06/2022.
8
9
10
11
12
13
14
LPA's observed 6 infants and 5 preschoolers in care during today's visit. No more than four infants are allowed in care at any time. Being over capacity poses immidiate risk and safety to children in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Winnie Ly
LICENSING EVALUATOR SIGNATURE:
DATE: 01/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2