384003092-11-13-2024-05-CC-JTSE-DAYQ8E-20241113105634

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 384003092
Report Date: 11/13/2024
Date Signed: 11/13/2024 10:56:55 AM

Document Has Been Signed on 11/13/2024 10:56 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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	CHAPMAN, NICOLE		FACILITY NUMBER:	384003092
ADMINISTRATOR/ DIRECTOR:	CHAPMAN, NICOLE D.		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(415) 508-9763
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94134
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 6	CENSUS: 4	DATE:	11/13/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:05 AM
MET WITH:	Licensee, Nicole Chapman		TIME VISIT/ INSPECTION COMPLETED:	11:10 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 11/13/2024, at approximately 8:05AM, Licensing Program Analyst (LPA) Jonathan Tse conducted an unannounced annual visit at the facility. LPA met with Licensee, Nicole Chapman (L1), and explained the purpose of the visit. Present during the visit was L1, a helper, and four preschool age children. The facility is operating within staffing and ratio requirements on this day. The facility’s operating hours are from 8:00AM to 6:00PM. Daycare Areas: Bedroom #1 (used for napping), Living Room, Kitchen, Bathroom, and Backyard. Off-limits Areas: Bedroom #2, Sun Room, Garage (used for passage into the Backyard only), and entirety of the Lower Level. LPA and Licensee inspected the home for any health or safety hazards. The home is equipped with an operational carbon monoxide detector. There are no fireplaces in the daycare areas. LPA observed the home to be equipped with a 3A40BC fire extinguisher which was last serviced in August 2024. LPA advised that the fire extinguisher shall be replaced due to lacking charge. Licensee stated that they understood. LPA observed childproof covers to be fitted on the Kitchen stove knobs. There are age-appropriate toys and learning materials present in the Living Room. Furniture is age-appropriate and free of rough or sharp edges. Per Licensee, the Kitchen is used for meals only. LPA observed cribs and mats to be present in Bedroom #1. There is a diaper changing station in Bedroom #1. Per Licensee, bedding is brought from home or provided at the facility as needed. Bedding is kept at the facility and cleaned once a week. The facility provides breakfast, lunch, and afternoon snacks for children in care. Licensee stated that there are no children enrolled with food allergies. LPA discussed appropriate storage of medication and documentation with Licensee during the visit. Continued on Page Two

SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024

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: CHAPMAN, NICOLE	FACILITY NUMBER: 384003092
	VISIT DATE: 11/13/2024

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
LPA observed the Backyard to be enclosed by a fence that is at least four feet high. Licensee stated a portion of the Backyard is used for art activities only. The remainder of the Backyard will not be used until renovation is started and completed. LPA advised that Licensee must notify the Department if alterations are being made to the facility. Licensee stated that children are taken outside to nearby parks that are within walking distance (8-10 minutes away). There are no swimming pools or similar bodies of water present in the facility. Per Licensee, there are no firearms or weapons in the home.

LPA reviewed two staff files, six children’s files, and facility records. Licensee’s Pediatric First Aid/CPR training expires 4/2026. Licensee does not have Mandated Reporter training on file. LPA advised that Mandated Reporter training must be completed every two years. Licensee stated that they understood. LPA observed children’s files to contain Emergency Identification and Information (LIC700) and Notification of Parents’ Rights (LIC995A). LPA advised Licensee to review children’s files and ensure that parents sign all relevant forms.

Per Licensee, the facility last conducted an emergency drill in the summer. LPA advised that emergency drills must be documented. A sample drill log was provided to Licensee during the visit. LPA verified the facility’s contact information to be current during the visit. All required postings were observed to be posted and available for review immediately upon entry to the facility.

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.
Continued on Page Three

SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024

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: CHAPMAN, NICOLE	FACILITY NUMBER: 384003092
	VISIT DATE: 11/13/2024

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
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.

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 deficiency cited today regarding Mandated Reporter training. See LIC9102-TV for technical violations issued today regarding emergency drills and fire extinguishers. 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, Nicole Chapman.

SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024

LIC809 (FAS) - (06/04)

Page: 3 of 6

Document Has Been Signed on 11/13/2024 10:56 AM - It Cannot Be Edited

Created By: Jonathan Tse On 11/13/2024 at 10:08 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: CHAPMAN, NICOLE	FACILITY NUMBER: 384003092
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.8662(b)(1)

Administration of Child Day Care Licensing

(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in two out of two staff files which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/27/2024
	Plan of Correction
1 2 3 4	Licensee and helper shall complete Mandated Reporter Training and submit proof of correction via email to LPA by set due date of 11/27/2024. Training can be found at mandatedreporterca.com.

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

LICENSING EVALUATOR NAME:

Jonathan Tse

LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024

LIC809 (FAS) - (06/04)

Page: 4 of 6