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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384000793
Report Date: 04/03/2024
Date Signed: 04/03/2024 12:54:40 PM

Document Has Been Signed on 04/03/2024 12:54 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:TEREMOKFACILITY NUMBER:
384000793
ADMINISTRATOR:
ADMINISTRATOR/
DIRECTOR:		FLORYA, IRINAFACILITY TYPE:
850
ADDRESS:2460 SUTTER STREETTELEPHONE:
(415) 441-3866
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94115
CAPACITY: 15TOTAL ENROLLED CHILDREN: 15CENSUS: 1DATE:
04/03/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
TIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Teacher, Antonina MishinaTIME COMPLETED:
TIME VISIT/
INSPECTION COMPLETED:
01:10 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 4/3/2024, at approximately 9:45AM, Licensing Program Analyst (LPA) Jonathan Tse conducted an unannounced annual visit at the facility. LPA met with staff member Antonina Mishina (S1). Director Irina Florya (D1) was not present during the visit today. LPA explained the purpose of the visit. Present during the visit was S1 and one preschool age child.

LPA inspected the facility for any health or safety hazards. LPA observed the facility to be in clean and orderly condition. The facility is equipped with a fully charged fire extinguisher. LPA observed a fire alarm system running throughout the facility. There are carbon monoxide and smoke detectors present in the facility. LPA observed an evacuation map with marked exit routes to be posted. There are age-appropriate toys and learning materials present. Furniture is observed to be age-appropriate and free of sharp or rough edges. LPA observed waste bins to be fitted with tight-fitting lids. Per S1, children sleep on cots and bring their own bedding from home. Bedding is taken home once a week for cleaning. The facility provides breakfast, lunch, and two snacks for children in care. LPA observed menus to be posted and available for review.

There is no outdoor play area located in the facility. The facility has a waiver to use an outdoor playground.

LPA reviewed two personnel files, one child’s file, and facility records. LPA observed personnel files to contain current Mandated Reporter Training. D1’s First Aid/CPR training is not from an EMSA certified vendor.

The child’s file was observed to be complete. LPA did not observe a Child Care Seat Law Poster (PUB269) to be posted. LPA observed that all other required postings were posted and accessible for review. The last emergency drill was conducted on 3/1/2024. Drills are properly logged and documented.
Continued on Page Two
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE: DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2024
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 6
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: TEREMOK
FACILITY NUMBER: 384000793
VISIT DATE: 04/03/2024
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
26
27
28
29
30
31
32
Page Two
Based on record review of lead testing documentation submitted to the Regional Office, LPA found that the facility was determined to not require lead sampling by a certified lead sampler, provided that the facility continues to provide water from an outside source. Per S1, fruits and vegetables are not washed on site and are provided from outside the facility. There are water bottles provided for children in care. LPA advised that an attestation be submitted by the facility stating that they do not provide drinking water or prepare food using fixtures within the facility. See LIC9102-TA for technical assistance given today.

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.

Facility representative was reminded that all adults 18 and over, 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 Child Care Center. 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.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test. For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP).

LPA referred facility representative to the Department website for lead: Lead Toxicity Prevention and Water Testing Information.



Continued on Page Three
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
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: TEREMOK
FACILITY NUMBER: 384000793
VISIT DATE: 04/03/2024
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
26
27
28
29
30
31
32
Page Three
Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, an updated Plan of Operation that includes 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) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care
Centers and the ADA are 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.

See LIC809-D for deficiencies cited today regarding First Aid/CPR training and personnel records. See LIC9102-TV for technical violation issued today regarding required postings. See LIC9102-TA for technical assistance provided today regarding lead water testing requirements. Appeal rights were provided to S1.
A notice of site visit was given and must remain posted for 30 days.

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

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 04/03/2024 12:54 PM - It Cannot Be Edited


Created By: Jonathan Tse On 04/03/2024 at 11:40 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: TEREMOK
FACILITY NUMBER: 384000793

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(f)
Personnel Requirements
(f) At least one staff member who is trained in pediatric cardiopulmonary resuscitation and pediatric first aid pursuant to Health and Safety Code Section 1596.866 shall be present when children are at the child care center or offsite for center activities.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above by not having First Aid/CPR training by the American Red Cross, American Heart Association, or an EMSA certified trainer, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2024
Plan of Correction
1
2
3
4
Licensee shall have all staff sign up for a Pediatric First Aid/CPR training provided by the American Red Cross, American Heart Association, or an EMSA certified trainer by set due date of 4/24/2024. Licensee shall provide proof of enrollment to LPA via email.
Type B
Section Cited
CCR
101217(d)
Personnel Records
(d) All personnel records shall be maintained at the child care center and shall be available to the licensing agency for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in one out of two staff members which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2024
Plan of Correction
1
2
3
4
Licensee shall have the following documents completed in S1's file: LIC503, LIC9052, LIC9108, staff qualifications (proof of enrollment in ECE courses), translated immunization records (MMR, Tdap, influenza). Licensee shall submit proof of completion to LPA via email.
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: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6