384004621-9-6-2022-05-CC-HLEG-CHZPZM-20220906114548

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 384004621
Report Date: 09/06/2022
Date Signed: 09/06/2022 11:45:59 AM

Document Has Been Signed on 09/06/2022 11:45 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	ZULHENDRI, FELICIA AND SIMAN, SUDHARMONO		FACILITY NUMBER:	384004621
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 0	DATE:	09/06/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:24 AM
MET WITH:	Felicia Zulhendri		TIME COMPLETED:	11:45 AM

NARRATIVE

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On 9/6/2022, Licensing Program Analyst (LPA), Hanson Leong, conducted a scheduled, pre-licensing inspection with the Applicant, Felicia Zulhendri. The applicant requested a visit from the department since she was relocating. The previous license number for the applicant is 384004548. The LPA was granted entry by the applicant. The LPA explained the purpose of the visit to the applicant. Guardian, the department's system for conducting background checks, has confirmed that all the individuals listed on the facility’s roster have been granted permission to work or be present in a childcare facility.

The applicant rents the home. The applicant intends to open from 8:30am to 5pm, Monday through Friday. The applicant states that she has purchased liability insurance for her home day care. The applicant plans to care for children ranging in age from twelve months to six years old.

Day care area(s): Living Room, Bedroom # 1, Patio, Kitchen, and Bathroom # 1

Off-limits area(s): Bedroom # 2 and Bathroom # 2. The applicant is aware off-limits areas are not to be used during business hours

Both LPA and the applicant conducted a health and safety inspection of the home. The house is clean and safe, with a working smoke, carbon monoxide detector and a fire extinguisher. The applicant has a first aid kit that is fully stocked with all the necessary supplies for treating injuries. There are no bodies of water in the residence. The applicant has garbage cans with tightly fitting covered lids. At the home, the children in care have access to age-appropriate toys and equipment. The applicant was reminded by the LPA that baby walkers, bouncers, jumpers, and similar items should not be used on children in care.

The applicant has a designated cell phone and is aware that it must be kept in the home during day care hours. According to the applicant, there are no firearms or weapons in the home. ***See Page 2 for continuation***

SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Hanson Leong
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2022

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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ZULHENDRI, FELICIA AND SIMAN, SUDHARMONO	FACILITY NUMBER: 384004621
	VISIT DATE: 09/06/2022

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Continued, Page 2
The front of the home will be the isolation area for a sick child. All hazardous materials and toxins are kept out of children's reach and are inaccessible. The applicant intends to serve snacks to the children. The applicant will provide cots and resting mats for the children while they are napping.

The LPA reminded the applicant that the CPR and First Aid training must be renewed every two years. The applicant has proof that she has received MMR and TDAP vaccinations. The applicant has completed the Mandated Reporter Training. The LPA reminded that the Mandated Reporter Training must be renewed every two years.

The LPA informed the applicant that emergency disaster drills should be conducted at least once every six months and that the date and time of the drill should be recorded. If the applicant provides care to the seventh and eighth child, who must be school aged, parent notification and landlord consent is required. The following is required to be posted in an accessible location in view of parents: Emergency Disaster Plan (LIC 610), Parent's Rights (LIC 995A), and License (once received).

The LPA discussed the safe sleep regulations and the Child Care Licensing Safe Sleep with the applicant, webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. The LPA also informed the applicant 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 with the applicant. For IMS information, see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes 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 the publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm
*** See Page 3 for continuation***

SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Hanson Leong
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2022

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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ZULHENDRI, FELICIA AND SIMAN, SUDHARMONO	FACILITY NUMBER: 384004621
	VISIT DATE: 09/06/2022

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A packet of forms pertaining to the children’s files and facility files were reviewed and discussed with the applicant. The applicant was advised all assistants, volunteers, frequent visitors or adults living in the home, over the age of 18 must be fingerprint cleared, associated to the home and have proof of immunization, prior to having any contact with the children in care. Failure to do so could result in an immediate civil penalty of $100 per person, each day.

The applicant was informed that as of September 1, 2016, a person may not be employed or volunteer at a child care facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662. The LPAs reviewed AB 1207 with the Licensee.

The LPA will recommend a Small Family Child Care Home License for the applicant. The applicant's new license will take effect on 9/6/2022

The applicant was advised to contact San Bruno Regional Office for concerns or questions. Desk Duty is available Mon-Fri, 8:00am to 5:00pm at (650) 266-8800. Forms and regulations are made available at www.cdss.ca.gov/inforesources/Community-Care-Licensing.

A copy of the report was given to the applicant

An exit interview was conducted, and the report was reviewed with the Applicant, Felicia Zulhendri

SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Hanson Leong
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2022

LIC809 (FAS) - (06/04)

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