384002330-7-9-2024-05-CC-LGOZ-D6ZU4B-20240709151453

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 384002330
Report Date: 07/09/2024
Date Signed: 07/09/2024 03:15:00 PM

Document Has Been Signed on 07/09/2024 03:15 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:	SMITH-RUSSACK, VIRGINIA		FACILITY NUMBER:	384002330
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 5	DATE:	07/09/2024
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Virginia Smith- Russack		TIME COMPLETED:	03:30 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 7/9/2024 at 1:10PM., Licensing Program Analysts (LPAs), Luis Gomez and Zeynep Basak met with Licensee, Virginia Smith- Russack. The purpose of today’s visit was explained and was for an unannounced, annual random inspection. Present was the licensee and licensee’s partner caring for 5 children. All children present are preschool-age. Adults have criminal record clearances on file. Per licensee, days and hours of operations are Monday- Friday, 8:30AM.- 5:30PM. Licensee’s home is a four bedroom, two bathroom, two level house. Area designated for childcare are the: Upper Level: Living room (Playroom #1); Bedroom #1; Kitchen; and Dining Area. Lower Level: Family room (Playroom #2/ Napping Room); and Backyard. Areas of the home designated as off-limits are Upper Level: Bedroom #2; Patio/ Deck Area; Lower Level: Bedroom #3; #4; Kitchenette; and Bathroom #2. LPAs inspected home, with the licensee for health and safety hazards. At 1:15PM., the following was observed: Facility was clean, neat, with age-appropriate playthings available for the children. The floors and ground surfaces were clear of obstructions. The off-limit areas have been made inaccessible with doors and child safety gates. Licensee’s furniture, books, and supplies inspected were in like-new condition. LPAs observed cubbies for storage of children’s belongings. Kitchen area has tables and chairs, scaled to the appropriate size. For napping services, LPAs observed individual mats stored in facility. Per licensee, napping supplies are changed/ washed weekly. Upstairs bathroom was observed clean, with fixtures in operating condition. Home was a comfortable temperature and well ventilated. Home had telephone service and fire extinguisher: 2A:10BC, located in kitchen. Per licensee, smoke/ carbon monoxide combination detector is functioning. (REFER TO 809C, FOR CONT.)

SUPERVISOR'S NAME: Marie Rodriguez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis Gomez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

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: SMITH-RUSSACK, VIRGINIA	FACILITY NUMBER: 384002330
	VISIT DATE: 07/09/2024

NARRATIVE

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At 1:35PM. LPAs inspected the Backyard Area. Areas was completely enclosed, with turf padded for added safety. Outside playthings inspected were in good repair. Home did not have any pools; fishpond; jacuzzi; or other bodies of water.

LPAs reminded licensee to remove potentially hazardous plants from outdoor play area. Advisory Note: Technical Violation (LIC9102TV) was issued.

At 2:15PM., LPAs reviewed facility records including the children and personnel files.
LPAs reminded licensee to ensure proof of required immunization are stored in facility records.

The children’s files were reviewed and included the: Notification of Parent’s Rights (LIC995); Identification and Emergency Information (LIC700); Consent for Medical Treatment (LIC627); and Immunization Record.

Licensee’s ‘Mandated Reporter Training Certification’ (AB1207) was current, expiring on: 8/2025.
Licensee’s Cardiopulmonary Resuscitation/ First Aid Certification (CPR) was current, expiring: 8/2025.
Licensee is conducting emergency disaster drill was last done on, 6/17/2024, and properly logged.

The required forms are posted in facility and include the: Child Care License; Notification of Parent’s Rights (PUB379). Emergency Disaster Plan (LIC610A) is posted in kitchen.

Per licensee, isolation of an ill child is in playroom #2. Per licensee, the program provides daily food services for children in care.

Facility was reminded that all adults 18 years and over living in the home, person who provides care and supervision to children, and staff who have contact with children, including employee and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain criminal 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. (REFER TO 809C, FOR CONT.)

SUPERVISOR'S NAME: Marie Rodriguez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis Gomez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

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: SMITH-RUSSACK, VIRGINIA	FACILITY NUMBER: 384002330
	VISIT DATE: 07/09/2024

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LPAs discussed the safe sleep regulations with licensee and the Child Care Licensing Safe Sleep Web page at:https://www.cdss.ca.gov/inforesource/child-care-licesning/public-information-and-resources/safe-sleep as an additional resource. LPA informed licensee of the importance of checking for recalled infant devices on United States consumer Product Safety Commission (CPSC) website at http://www.cpsc.gov and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Facility was informed of the www.mychildcareplan.org site is a consumer education website that helps families obtain child care by connecting to child care providers and resources and referral agencies (R&R) throughout California.

Incidental Medical Services (IMS) policy was discussed. For IMS information, see PIN 20-02-CCP. When an IMS is provided, a plan for 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- 0382 (TTY) and link to publications: Commonly asked questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

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 tool, please send them 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/inforesource/community-care-licensing/inspection-process.

Based on today's inspection, no deficiencies were cited in areas evaluated according to California Title 22, Div. 12 Chap. 3, Ca Health and Safety, Code of Regulations. Exit interview and report was reviewed with Licensee, Virginia Smith-Russack. Licensee’s signature of this form acknowledges the receipt of these documents.

During exit interview, licensee confirmed no registered sex offenders are living in the facility and LPA completed RSO profile. Notice of site visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Marie Rodriguez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis Gomez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

LIC809 (FAS) - (06/04)

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