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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004457
Report Date: 09/12/2024
Date Signed: 09/12/2024 10:12:49 AM

Document Has Been Signed on 09/12/2024 10:12 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 CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:MASSA, SHAYNA L.FACILITY NUMBER:
384004457
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 6CENSUS: 6DATE:
09/12/2024
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:25 AM
MET WITH:Loren Cervantes and Shayna MassaTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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On September 12, 2024, Licensing Program Analyst (LPA) Van conducted an unannounced inspection to review the licensee's request to increase her license capacity. Upon arrival, LPA was met by the licensee's assistant, Loren Cervantes, who informed LPA that the licensee had gone out for a dog walk but returned during the visit. At that time, the assistant was overseeing three children (two infants and a preschooler). The facility is open Monday through Thursday from 8:00 am to 5:30 pm and Fridays from 8:00 am to 4:00 pm. Three more children arrived during the visit (one infant and two preschoolers). Bring the total to 6 children.

LPA inspected the facility for health and safety hazards. According to the licensee, no changes to the physical plan were previously approved. The childcare facilities are situated solely on the ground floor and consist of three rooms, a kitchenette, and a backyard. One room is designated for activities, another for naps, and the third serves as the licensee's office, isolation room, and additional nap space if needed. The off-limit areas are the entire first and second levels and the garage.

The childcare areas are clean and have age-appropriate toys and learning materials. There is age-appropriate furniture, which is sturdy and in good repair. The facility floor is in good repair and free of any hazards. The children's bathroom is in good working condition and has proper sanitation. All the materials and surfaces accessible to children are clean and toxins-free. The facility has no pools, spas, or other bodies of water. The facility has a smoke detector, carbon monoxide detector, fully charged fire extinguishers, and a working telephone. All the cleaning solutions, poisons, and other chemicals that are dangerous to the children are stored and inaccessible to the children.
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SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2024
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: MASSA, SHAYNA L.
FACILITY NUMBER: 384004457
VISIT DATE: 09/12/2024
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According to the licensee, the Fire marshal had inspected childcare and approved the clearance. However, the Department has not received the Fire Clearance form, STD 850.

During the inspection, the following was discussed and reviewed with the Licensee:

· Licensee was 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.
· Incidentals 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: http://www.ada.gov/childqanda.htm
· The Licensee was given information regarding PIN 20-24-CCP Safe Sleep Regulation
· The Licensee was reminded that as of September 1, 2016, all Staff and Volunteers must provide proof of immunization against pertussis, measles, and influenza or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.622.
· The Licensee was reminded about Mandated Reporter training available on the CCLD website. All staff hired must complete training every two years. Training can be taken online at www.mandatedreporterca.com. If training is unavailable in the native language, a statement can be written stating exemption until the translation is available.
· The Licensee was reminded about the Provider Information Notices (PINs) on the CCLD website.
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SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
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: MASSA, SHAYNA L.
FACILITY NUMBER: 384004457
VISIT DATE: 09/12/2024
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·Mandatory Posting Requirements: License, Emergency Disaster Plan, and Notification of Parents Rights Poster.
· The capacity limit of a large license was discussed with the Licensee. The Licensee was reminded that a Helper must be present when operating at a large capacity. In addition, Pediatric FirstAid CPR is required for all helpers.

The licensee's proof of control of property was on file.
Because the licensee rents/leases the home, proof of landlord notification is required. The LPA observed the Property Owner/Landlord Notification form (LIC9151) that the applicant confirms was provided to the property owner/landlord. The applicant obtained a signed Property Owner/Landlord Consent form (LIC 9149).

Once the fire clearance form STD 850 is received from the fire marshal, a recommendation to increase the capacity of a large family childcare home will be made.

A notice of site visit was given to the licensee and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

Exit interview was conducted and the report was reviewed with the licensee, Shayna Massa
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
LIC809 (FAS) - (06/04)
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