<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414002627
Report Date: 08/23/2022
Date Signed: 08/23/2022 12:05:27 PM

Document Has Been Signed on 08/23/2022 12:05 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:RUSSELL, CARRIE J.FACILITY NUMBER:
414002627
ADMINISTRATOR:RUSSELL, CARRIE J.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 341-0944
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
08/23/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Carrie RussellTIME COMPLETED:
10:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Marie Rodriguez conducted an unannounced joint case management inspection with San Mateo Deputy Fire Marshal Melinda Martin and City of San Mateo Code Enforcement Officer John Freitas. LPA, Deputy Fire Marshal, and Code Enforcement Officer met with Licensee Carrie Russell and explained purpose of inspection. Present in the home were the Licensee, Licensee's husband, Licensee's adult daughter, and nine children (two infants and seven preschool aged).

LPA provided Deputy Fire Marshal with the home's facility sketches and a new STD 850 Fire Safety Inspection Request form as requested. Deputy Fire Marshal and Code Enforcement Officer conducted tour of home. Deputy Fire Marshal will conduct follow up fire inspection with Licensee on a separate date.

After inspection was completed by Deputy Fire Marshal and Code Enforcement Officer, LPA informed Licensee that annual fee was overdue and provided her with amount due of $210 and PIN to make payment on CCLD's website. Licensee stated she will notify LPA once payment has been made.

No deficiencies cited today under California Code of Regulations, Title 22, Division 12.

LPA will email Licensee copy of report to confirmed email address and will request for Licensee to respond to email to confirm report has been received. This will serve as Licensee's electronic signature of report.
SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Marie Rodriguez
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2022
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 1