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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414001599
Report Date: 04/26/2023
Date Signed: 06/08/2023 09:15:25 AM

Document Has Been Signed on 06/08/2023 09:15 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:ZACK, JERBANU PERVEZFACILITY NUMBER:
414001599
ADMINISTRATOR:ZACK, JERBANUPERVEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 627-8418
CITY:FOSTER CITYSTATE: CAZIP CODE:
94404
CAPACITY: 14TOTAL ENROLLED CHILDREN: 7CENSUS: 3DATE:
04/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:22 AM
MET WITH:Jerbanu ZackTIME COMPLETED:
11:15 AM
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On April 26, 2023. Licensing Program Analyst (LPA) Maria Olguin-Leon and (LPM) Ali Zebila met with Licensee, Jerbanu Zack, for an unannounced annual inspection. The purpose of the inspection was explained. Present today is Licensee, helper and 6 preschool children. Licensee is operating within capacity and ratio requirements on this day. Licensee and helper have criminal record clearances on file with the department. Hours of operation are Monday– Friday, 8:30am to 5:30pm.

LPA and Licensee toured the home for health and safety hazards. The home is a two-story level home. Day Care Areas: Living Room, Dining Room, downstairs bathroom, and backyard. Off Limits Areas: Kitchen and entire upstairs which is properly barricaded with child proof gate. The home is clean and has proper ventilation. Cleaning supplies and other potentially harmful items are stored inaccessible to the children. There are plenty of age-appropriate toys, child size furnishings, learning material and sleeping mats. Parents provide sheets and are sent home for weekly washing. Outdoor play area has play structure, riding toys, Backyard is completely fenced and has artificial grass to cushion falls. There are no pools, spas, or other bodies of water on the property. Licensee provides and cooks meals for children in care. LPA observed food to be properly stored to avoid contamination.

The home is equipped with a carbon monoxide detector, smoke detector and a fully charged fire extinguisher located in kitchen. Isolation area for ill children is in living room away from other children. First aid kit is fully stocked with supplies. Home is equipped with a landline and Licensee has a cell phone. Per licensee there are no weapons or firearms in the home.

LPA reviewed 5 children’s records and all required documents were in children’s files. Helper file is complete with CPR/First Aid, Mandated Reporter, Immunization's records, and all other required documents. Licensee CPR/First Aid is current and will expire on 02/2025. Mandated Reporting will expire 04/2024. Children’s roster was reviewed and is up to date. Last emergency drill was documented on 2/09/2023. Licensee has liability insurance through DCI Insurance.

Cont. page 2...
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Maria Olguin-Leon
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2023
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 CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: ZACK, JERBANU PERVEZ
FACILITY NUMBER: 414001599
VISIT DATE: 04/26/2023
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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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. Where 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 and Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

The Licensee was reminded about the Provider Information Notices (PINs) on the CCLD website. Licensee was informed that as of September 1, 2016, a person may not be employed or volunteer at a childcare 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. LPA reviewed AB 1207 with the Licensee. As of January 1, 2018, all staff must complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com.

LPA encouraged the Licensee to frequently visit our website at www.ccld.ca.gov for licensing regulations and new updates. The Licensee can also email at childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list for the updates.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.



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SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Maria Olguin-Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023
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: ZACK, JERBANU PERVEZ
FACILITY NUMBER: 414001599
VISIT DATE: 04/26/2023
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A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

As of today, based on observation and file reviews, facility is currently in substantial compliance with title 22.
Exit interview conducted and report was reviewed with the licensee, Jerbanu Zack
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Maria Olguin-Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023
LIC809 (FAS) - (06/04)
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