384002701-5-21-2024-05-CC-BVAN-D5GRYV-20240521132700

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 384002701
Report Date: 05/21/2024
Date Signed: 05/21/2024 01:27:08 PM

Document Has Been Signed on 05/21/2024 01:27 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 CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	JUN & NORIKO KUBOTA		FACILITY NUMBER:	384002701
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 6	DATE:	05/21/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Noriko Kubota and Jun Kubota		TIME COMPLETED:	01:30 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 May 21, 2024, Licensing Program Analyst (LPA) Van conducted a random annual inspection and met the Co-licensee, Noriko Kubota. LPA explained the purpose of the inspection to the Licensee, and LPA was granted entry into the apartment unit. Upon entering the unit, LPA observed the co-licensee and her helper preparing and setting up tables for the children to get ready for lunch. The co-licensee and a helper supervised six children: four preschoolers and two infants. During the visit, the other co-licensee, Jun Kubota, came home. The licensees comply with the licensing capacity and limits today. All adults present during the inspection have had criminal clearance verified by the CDSS Guardian System. According to the licensees, the previously approved childcare areas remain the same, with the same off-limits and childcare areas. The childcare areas are the living room and bathroom #1. There are no outdoor areas. The off-limit areas are the two bedrooms, the kitchen, and the bathroom #2. All off-limit areas are appropriately barricaded. The days and hours of operation are Monday through Friday from 8:30 a.m. to 5:30 p.m. LPA inspected the childcare areas for any potential dangers to health and safety hazards. LPA observed that the childcare areas were clean and in good condition. There was no fireplace in the unit. All the materials and surfaces accessible to children are clean and toxins-free. There were age-appropriate toys such as imaginative, creative, and manipulative play. The childcare areas have appropriate heating, lighting, and ventilation. LPA reminded the Licensees and emphasized the importance of covering all electrical wires to prevent children from pulling on them. Licensees have indicated that they will buy electrical covers and install them. Continued on page 2...

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon Van	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024

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 CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: JUN & NORIKO KUBOTA	FACILITY NUMBER: 384002701
	VISIT DATE: 05/21/2024

NARRATIVE

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The unit had a fully charged fire extinguisher that met the minimum standard of 2A 10 BC, a carbon monoxide detector, and a centralized smoke alarm. A functional phone was also available in case of emergencies. All cleaning agents and detergents were stored in the kitchen off-limit area. The licensees stated that no firearms or weapons were present on the premises. LPA did not observe baby walkers, bouncers, or similar equipment in the childcare areas, and the licensees were reminded that smoking is prohibited in the family childcare home.

During the inspection, LPA noticed a play yard in the living room area with no toys, blankets, or pillows inside. The padding used in the playpen was a perfect fit for its dimensions. Licensees provided LPA with the infants sleeping logs. LPA noticed that the licensees maintained the infant's sleep log appropriately.

All the required posting documentation, such as the facility license, Notification of Parental Rights, and Earthquake Preparedness Checklist, have been placed in a prominent area for parents or representatives to review. According to the licensee, regular fire and earthquake drills are conducted at least once every six months, with the most recent drills completed on 1/8/2024.

The records of all the children who were present were reviewed. The facility maintains accurate records for each child, including vaccination records, parental rights forms, and complete emergency information. These emergency documents contain information such as the child's full name, phone number, and the location of a parent or authorized person who may be contacted in an emergency. The records also contain the name and phone number of the child's doctor and the parent's permission for the licensee to consent to emergency medical care if needed.

Licensees and a helper have maintained complete records and met all the necessary licensing requirements, including completing required immunizations, mandated reporter training, and maintaining valid Pediatric CPR/First Aid certification.
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SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon Van	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

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 CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: JUN & NORIKO KUBOTA	FACILITY NUMBER: 384002701
	VISIT DATE: 05/21/2024

NARRATIVE

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Licensees were reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with the licensees and discussed the Child Care Licensing Safe Sleep webpage https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed the licensees 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: www.ada.gov/childqanda.htm.

Licensees were reminded about the Provider Information Notices (PINs) on the CCLD website. Licensees were informed that as of September 1, 2016, a person may not be employed or volunteer at a childcare facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662.
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SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon Van	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

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 CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: JUN & NORIKO KUBOTA	FACILITY NUMBER: 384002701
	VISIT DATE: 05/21/2024

NARRATIVE

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LPA reviewed AB 1207 with the Licensees. As of January 1, 2018, all staff must complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com.

Licensees were informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

During the exit interview, the CO-LICENSEE, JUN KUBOTA, confirmed that there are no Registered Sex Offenders living in the facility, and LPA completed the RSO profile in FAS.

A notice of site visit was given and must remain posted for 30 days.

An exit interview was conducted, and the report was reviewed with the licensee, Jun Kubota.

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon Van	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

LIC809 (FAS) - (06/04)

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