384001433-2-28-2024-05-CC-JTSE-D2VVZX-20240228155328

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 384001433
Report Date: 02/28/2024
Date Signed: 02/28/2024 03:53:46 PM

Document Has Been Signed on 02/28/2024 03:53 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:	TSEGAYE, BETHLEHEM		FACILITY NUMBER:	384001433
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 5	DATE:	02/28/2024
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Licensee, Bethlehem Tsegaye		TIME COMPLETED:	04:10 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 2/28/2024, at approximately 2:20PM, Licensing Program Analyst (LPA) Jonathan Tse conducted an unannounced annual visit at the facility. LPA was granted entry to the facility by Licensee, Bethlehem Tsegaye. LPA explained the purpose of the visit. Present during the visit was the Licensee and five infants. The facility’s operating hours are from 9:00AM to 5:00PM. Daycare Areas: Kitchen, Formal Dining Room, and Bathroom. Off-limits Areas: Bedroom #1, Bedroom #2, Dining Room, Living Room, and Laundry Room. LPA inspected the home for any health and safety hazards. LPA observed the home to be in orderly condition. The home is equipped with a carbon monoxide detector. There is a fully charged 3A40BC fire extinguisher. There is a fireplace in the Formal Dining Room that is obstructed by furniture to be inaccessible to children in care. LPA observed cribs to be available for each infant in care. There are age-appropriate toys and learning materials present in the Kitchen. Off-limits areas and stairs are secured by childproof gates. At 2:40PM, LPA observed an infant sleeping in a crib with a milk bottle. LPA discussed safe sleep regulations that pertain to keeping cribs free of loose articles and objects. Licensee removed the bottle from the crib during the visit. There is no outdoor play area in the facility. Licensee takes children outside for walks and playtime. There are no pools or other bodies of water present in the facility. Per Licensee, there are no weapons or firearms in the home. LPA reviewed facility records and five children’s files. Licensee’s First Aid/CPR training expires on 4/2025. LPA found that all children’s files included Emergency Identification and Information (LIC700), Consent for Emergency Medical Treatment (LIC627), and Notification of Parents’ Rights (LIC995). Continued on Page Two

SUPERVISOR'S NAME: Ali Zebila	TELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Jonathan Tse	TELEPHONE: (650) 464-4927
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024

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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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: TSEGAYE, BETHLEHEM	FACILITY NUMBER: 384001433
	VISIT DATE: 02/28/2024

NARRATIVE

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Based on record review at 2:50PM, LPA confirmed that all children present in the home during visit are infants. Licensee is operating over capacity with five infants.

LPA observed the facility license to be posted in a visible and accessible area of the hallway leading to the daycare areas.

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.

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.

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.

Continued on Page Three

SUPERVISOR'S NAME: Ali Zebila	TELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Jonathan Tse	TELEPHONE: (650) 464-4927
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024

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: TSEGAYE, BETHLEHEM	FACILITY NUMBER: 384001433
	VISIT DATE: 02/28/2024

NARRATIVE

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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/.

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

See LIC809-D for one Type-A and one Type-B deficiency cited during today’s visit on 2/28/2024. Appeal rights were provided and explained to Licensee.
A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee, Bethlehem Tsegaye.

LPA Tse informed Licensee Bethlehem Tsegaye that this report dated 2/28/2024 documents one Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Tse informed the Licensee to provide a copy of this licensing report dated 2/28/2024 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.

SUPERVISOR'S NAME: Ali Zebila	TELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Jonathan Tse	TELEPHONE: (650) 464-4927
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/28/2024 03:53 PM - It Cannot Be Edited

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: TSEGAYE, BETHLEHEM	FACILITY NUMBER: 384001433
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

102416.5(b)(1)

Staffing Ratio and Capacity

(b) For a Small Family Child Care Home, the maximum number of children for whom care may be provided at any one time, including children under age 10 who reside at the licensee's home, shall be one of the following: (1) Four infants; or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above by having five infants in care which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/29/2024
	Plan of Correction
1 2 3 4	Licensee shall adjust schedules of children in care so that there are only four infants in care at any time, or up to 3 infants and 3 preschoolers at a time, by the set due date of 2/29/2024. Licensee shall provide LIC9224 to all parents and maintain a signed copy in each child's file.

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	TELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Jonathan Tse	TELEPHONE: (650) 464-4927
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/28/2024 03:53 PM - It Cannot Be Edited

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: TSEGAYE, BETHLEHEM	FACILITY NUMBER: 384001433
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(b)

Infant Safe Sleep

(b) Cribs or play yards shall be free from all loose articles and objects. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by not removing a milk bottle from an infant's crib which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/06/2024
	Plan of Correction
1 2 3 4	Licensee removed the bottle from the crib during the visit. Licensee shall maintain all cribs so that they are free of loose articles and objects.

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	TELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Jonathan Tse	TELEPHONE: (650) 464-4927
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024

LIC809 (FAS) - (06/04)

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