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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004196
Report Date: 03/13/2025
Date Signed: 03/13/2025 10:24:07 AM

Document Has Been Signed on 03/13/2025 10:24 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:KELLEY, SHIRINFACILITY NUMBER:
384004196
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 5CENSUS: 2DATE:
03/13/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:35 AM
MET WITH:Shirin KelleyTIME VISIT/
INSPECTION COMPLETED:
10:45 AM
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On March 13, 2025 at approximately 8:35am, Licensing Program Analyst (LPA) Catrina Quimbo conducted an unannounced, annual inspection. LPA met with license, Shirin Kelley, and explained the purpose of the visit. Present during LPA's visit included licensee and 2 enrolled children (1 preschool age and 1 infant). Licensee is operating within capacity limits and ratio during LPA's visit.

Licensee operates Monday through Friday 8:30am to 5:00pm. Licensee lives in the multi-level home with their spouse and 3 minor children. All adults living in the home have fingerprint clearance on file. Licensee operates their family childcare home on the ground level of the home only.

The DAY CARE AREAS are the outdoor deck area, activity room (lobby area), bedroom #1 (main day care area), and bathroom #1. The OFF LIMIT AREAS are the garage (ground level) and entire second level of home. There is internal access to the second level of the home through the garage. LPA observed garage is made inaccessible with a dead bolt.

LPA inspected day care areas for health and safety hazards. Main day care area includes a variety of toys and materials in good condition. There is furniture for children's use that are age appropriate. Home is appropriately ventilated with heat and is comfortable. Main day care area includes carpet and rugs that are clean, free of stains. There is a ledge in the main day care area that is padded for additional safety. LPA did not observe accessible, electrical outlets in day care areas. LPA did not observe accessible cleaning solutions or poisons in home.

LPA observed a fully charged fire extinguisher, carbon monoxide detector, and first aid kit in the home. LPA tested carbon monoxide detector during today's visit, which was observed to be working.

Backyard is fully fenced and enclosed. Backyard includes a variety of outdoor toys and equipment that are in good condition. LPA did not observe any pools, spas or bodies of water on site.
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SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2025
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: KELLEY, SHIRIN
FACILITY NUMBER: 384004196
VISIT DATE: 03/13/2025
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Children sleep in the main day care area in "pack and play" cribs. LPA did not observe a crib with loose blankets or materials stored. Per licensee, infants sleeping in cribs do not sleep with loose articles, including blankets, sleeping sacks or pillows. Licensee maintains a sleeping log for napping infants. LPA observed sleeping log to document every 15 minutes of when the napping infant is checked on by licensee. LPA reviewed sleeping logs from January 2025 through March 2025.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage athttps://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.

LPA observed bathroom for children's use to be clean and in working condition. Bathroom is equipped with age appropriate toileting equipment. There is a diaper changing table in the bathroom that is within arm's reach to a sink. Per licensee, children's families provide diapers and wipes. LPA observed a garbage bin with a tight fitting lid in bathroom. LPA also observed cabinets in bathroom to have child safety locks installed.

Licensee provides a food service that includes snack and lunch. No children currently enrolled have allergies. Per licensee, if a child had an allergy, food child may be allergic to will be omitted from food menu. Isolation area for sick children is located in the main day care area, separate from other children in care.

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/.

LPA reviewed facility records that included five children's records and licensee's record. Children enrolled have complete records with emergency information and immunization records. Licensee has proof of their required immunizations, that were made available for LPA's review. Licensee's CPR/First Aid certification is current and will expire 01/2027. LPA reminded licensee Mandated Reporter training must be renewed every two years by all staff working with children. Technical violation was issued during today's visit.
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SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
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: KELLEY, SHIRIN
FACILITY NUMBER: 384004196
VISIT DATE: 03/13/2025
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Licensee has licensing documentation properly posted and available for review. Licensee maintains a childcare roster that was made available for LPA's review. Disaster drills are conducted monthly and are properly documented. LPA reviewed disaster drills from December 2024 through February 2025. Discipline policy was discussed with licensee. Per licensee, children are redirected. There is a pet in the home is kept in the off limit areas of home, separate from children in care. Per licensee, there are no weapons or firearms in the home. LPA reminded licensee of annual fees to be paid for license.

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.

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

No deficiencies were issued today during LPA's visit.

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

Exit interview conducted and report was reviewed with the licensee, Shirin Kelley.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
LIC809 (FAS) - (06/04)
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