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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004438
Report Date: 03/18/2024
Date Signed: 03/18/2024 01:40:29 PM

Document Has Been Signed on 03/18/2024 01:40 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:AMARSAIKHAN,DELGERMAAFACILITY NUMBER:
384004438
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 4CENSUS: 4DATE:
03/18/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:04 PM
MET WITH:Tsoggerel Uranazagilaa, sisrter/helper & Licensee, Delgermaa Amarsaikhan TIME COMPLETED:
01:50 PM
NARRATIVE
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On March 18, 2024, at approximately 11.20am, Licensing Program Analyst (LPA) Tso met with the licensee’s sister/helper, Tsoggerel Uranazagilaa (does not understand English) for an unannounced inspection of the Plan of Correction (POC). The Licensee, Delgermaa Amarsaikhan was not in the facility. LPA called and spoke to the licensee. Per the licensee, she is now in the hospital to have a tooth surgery. The purpose of the inspection was explained, and the Licensee granted LPA entry to the home. The licensee informed LPA that she would be returned to the facility in an hour. The licensee returned to the facility at 12.45pm. Present, there were four children (2 infant and 2 pre-school aged) in care with the Licensee’s sister/helper.

During the required annual inspection on March 01, 2024, the Licensee received citations for two deficiencies. The Type B was cited deficiencies were the licensee fails to conduct and record the emergency drill in every six months, the last emergency drill was conducted on 7/1/2023. Per the licensee, the fire drill was conducted at 2pm on March 6, 2024. The licensee present drill log to LPA.

Deficiency cited on March 01, 2024, were cleared today. Plan of Correction letters were provided to the Licensee.

However, during today's inspection, LPAs observed that the licensee’s sister/helper who has not obtained the criminal background check clearance to take care of children in the facility. Per the licensee, she has a tooth surgery today (3/18/2024) and asked her sister to take care of children for today only. Her sister would not be the facility during the operating hours of the facility afterwards. A type A deficiency citation is issued. LPA assessed a civil penalty of $100 (see LIC421BG).

See LIC809D for Type "A" deficiency and LIC421BG issued today. The facility is advised to provide a copy of the Evaluation Report and the Type "A" Deficiency cited to the parents and guardians of children currently.
enrolled in care and parents of newly enrolled children during the next 12 months. A signed and dated LIC
9224 shall be maintained in all Children's files. This report will be maintained in the facility file and made
available for public review three years after the thirty-day posting requirement has been met.
A copy of today’s report, LIC 421BG, and the facility’s appeal rights were discussed and given to the 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, Delgermaa Amarsaikhan
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Man Tso
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2024
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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Document Has Been Signed on 03/18/2024 01:40 PM - It Cannot Be Edited


Created By: Man Tso On 03/18/2024 at 01:16 PM
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: AMARSAIKHAN,DELGERMAA
FACILITY NUMBER: 384004438

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/19/2024
Section Cited
CCR
102370(d)(1)

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102370 Criminal Record Clearance (d) All
individuals subject to a criminal record review…
shall prior to working … in a licensed facility:
(1) Obtain a California clearance
This requirement is not met as evidenced by:
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The Licensee must ensure that all adults 18 and over living or working in the home,
including employees and volunteers, must
obtain a criminal record clearance. The
Licensee states the adult will obtain the criminal record clearance before the adult can return to the facility
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Based on observation, interviews and record review, Licensee did not ensure the adult sister/helper obtaining the criminal record clearance before providing care to the children, which pose an immediate health, safety, or personal rights risk
to persons in care.
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Per the licensee, she has a tooth surgery today (3/18/2024) and asked her sister to take care of children for today only. Her sister would not be the facility during the operating hours of the facility afterwards. LPA observed the lciensee's sister/helpr left the facility at 1.10pm.

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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:Garfield Leung
LICENSING EVALUATOR NAME:Man Tso
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2024


LIC809 (FAS) - (06/04)
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