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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414001557
Report Date: 01/17/2024
Date Signed: 01/17/2024 10:08:51 AM

Document Has Been Signed on 01/17/2024 10:08 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:DUBOIS, KARLA M.FACILITY NUMBER:
414001557
ADMINISTRATOR:DUBOIS, KARLA M.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 571-5054
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
01/17/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Licensee, Karla DuBoisTIME COMPLETED:
10:20 AM
NARRATIVE
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On 1/17/2024, at approximately 8:30AM, Licensing Program Analyst (LPA) Jonathan Tse conducted an unannounced annual visit at the facility. LPA was granted entry to the facility by the Licensee, Karla DuBois. LPA explained the purpose of the visit. Present in the facility was Licensee, Licensee’s spouse, and Licensee’s adult daughter. There are no children in care on this day. All adults living or working in the home have acquired fingerprint clearance and are associated to the facility.

Daycare Areas: Kitchen, Living/Dining Room, Bathroom #1, Playroom (used for napping) and Backyard.
Off-limits Areas: Bedroom #1, Bedroom #2, Bathroom #2, Office (only used as passthrough into the Playroom) and Garage.

LPA and Licensee inspected the home for any health and safety hazards. LPA observed the home to be in clean and orderly condition. The home is equipped with a 2A10BC fire extinguisher that is fully charged. Licensee demonstrated that the combination smoke and carbon monoxide detector in the Living Room was operational. There is a fireplace present in the living room that is covered to be inaccessible to children in care. LPA observed all electrical outlets to be covered or obstructed by furniture. There are age-appropriate toys and equipment in the home that are in good repair. Licensee provides mats and sheets for children to nap on. Poisons, detergents, and other chemicals are stored inaccessible to children in care. Off-limits areas are secured by childproof gates or childproof covers on the doorknobs. Per Licensee, there are no firearms or weapons stored in the facility.

The Backyard was observed to be free of debris and other loose articles. It is enclosed by a fence that is at least five feet high. There are no pools or other bodies of water present in the facility.

LPA reviewed Licensee’s file. Licensee’s First Aid/CPR training expires 6/2024. Licensee’s Mandated Reporter Training expires 1/2026. Immunization records are available for review.
Continued on Page Two
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: DUBOIS, KARLA M.
FACILITY NUMBER: 414001557
VISIT DATE: 01/17/2024
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LPA observed all required postings to be in a visible and accessible area of the home. Licensee provides breakfast, lunch, and AM/PM snack for children in care.

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.

LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep webpage at https://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.

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/.

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SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024
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 CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: DUBOIS, KARLA M.
FACILITY NUMBER: 414001557
VISIT DATE: 01/17/2024
NARRATIVE
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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, Licensee, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

No deficiencies were cited during today’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, Karla DuBois.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024
LIC809 (FAS) - (06/04)
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