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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004338
Report Date: 06/07/2024
Date Signed: 06/07/2024 01:36:34 PM


Document Has Been Signed on 06/07/2024 01:36 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:CHULUUN,SARANFACILITY NUMBER:
384004338
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 3DATE:
06/07/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:16 PM
MET WITH:Saran ChuluunTIME COMPLETED:
01:50 PM
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On June 7, 2024, at approximately 1.10pm, Licensing Program Analyst (LPA) Tso met with the Licensee, Saran Chuluun for an unannounced inspection of the Plan of Correction (POC). The purpose of the inspection was explained, and the Licensee granted LPA entry to the home. There were three children (I infant and 2 preschool aged) in care with the Licensee and a helper.

During the required annual inspection on May 20, 2024, the Licensee received citations for two deficiencies. The type B was cited deficiencies for not comply with the section cited that putting 2 infants napping in a separate room with the door closed, and an infant wearing a sleep sack to sleep. In addition, the Licensee received several technical violations, including the helper missing Mandared Reporter Training certificate, missing emergency drill record, missing 2 children's parents’ rights documents (Form LIC995A), and 15-minute sleeping check log. LPA did not observe any infant wearing sleep sack when napping. LPA observed an infant napping in a room with the door open. LPA reviewed the records of emergency drills, records of LIC995A, 15-minute sleeping check log, the helper’s mandated reporter training certificate, and found that the licensee conducted them correctly and logged them accurately. LPAs observed the Notice of Site Visit posted.

Deficiencies cited on May 20, 2024, were cleared today (June 7, 2024). Plan of Correction Clearance letter was provided to the Licensee.

No deficiencies were cited during today’s visit. A notice of site visit was provided and must remain posted for 30 days.

Exit interview was conducted with the Licensee, Saran Chuluun.
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8867
LICENSING EVALUATOR NAME: Man TsoTELEPHONE: (650) 379-9021
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2024
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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