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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414002627
Report Date: 11/16/2023
Date Signed: 11/16/2023 05:08:08 PM

Document Has Been Signed on 11/16/2023 05:08 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
SAN BRUNO CC RO, 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: 12DATE:
11/16/2023
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Carrie RussellTIME COMPLETED:
05:25 PM
NARRATIVE
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On 11/16/2023, at approximately 1:30PM, Licensing Program Analyst (LPA) Jonathan Tse conducted an unannounced annual visit at the facility. LPA was granted entry to the facility by licensee, Carrie Russell. LPA explained the purpose of the visit. Present during the visit were seven school-age children, four preschool age children, and one infant. There was one helper present. The licensee's adult son and daughter were present in the home.

LPA and Licensee inspected the daycare areas for any health and safety hazards. The building is a two story, four bedroom, 1.5 bathroom home.

Daycare Areas: Playroom, Living room, Kitchen, half-bathroom located on first floor, and Front Yard.

Off-Limits Areas: Bedroom 1, Bedroom 2, Bedroom 3, Bedroom 4, Garage, Bathroom located on second floor, upstairs Living Room, upstairs Deck, and Backyard.

LPA observed the daycare areas to be in orderly condition. LPA observed there to be age-appropriate toys and learning material for children in care. The living room is used as a napping area when children need to nap. Licensee demonstrated the carbon monoxide detector located in the hallway to be operational. There is an operational smoke detector present in the facility. The facility is equipped with a fully charged 3A40BC fire extinguisher. Licensee has first aid materials present in a kitchen cupboard. There are no external heaters or fireplaces present in the home.

LPA observed the front yard to be in good condition. There is sufficient cushioning for children in care. Play structures and equipment are in good and usable condition.

Continued on Page Two
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2023
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 9
Document Has Been Signed on 11/16/2023 05:08 PM - It Cannot Be Edited


Created By: Jonathan Tse On 11/16/2023 at 03:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: RUSSELL, CARRIE J.
FACILITY NUMBER: 414002627

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(4)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in two items left out in daycare areas, detergent and a power tool, which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/23/2023
Plan of Correction
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Licensee promptly removed the detergent and power tool from daycare areas and placed them in an off-limits area. LPA and Licensee discussed maintenance of daycare areas in regards to keeping potential hazards out of children's reach.
Type B
Section Cited
HSC
1596.871(c)(1)(A)
Administration of Child Day Care Licensing
Subsequent to initial licensure, a person specified in subdivision (b) who is not exempt from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification, pursuant to subdivision (f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/30/2023
Plan of Correction
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Licensee will contact Guardian and proceed with the fingerprinting process or restart the fingerprinting process for her helper. Licensee will then submit proof of the fingerprinting process to LPA.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Ali Zebila
LICENSING EVALUATOR NAME:Jonathan Tse
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2023


LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 11/16/2023 05:08 PM - It Cannot Be Edited


Created By: Jonathan Tse On 11/16/2023 at 03:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: RUSSELL, CARRIE J.
FACILITY NUMBER: 414002627

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/30/2023
Plan of Correction
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Licensee and all helpers present in the home will complete Mandated Reporter Training and submit certificates of completion to LPA.

https://mandatedreporterca.com/
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Ali Zebila
LICENSING EVALUATOR NAME:Jonathan Tse
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2023


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 CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: RUSSELL, CARRIE J.
FACILITY NUMBER: 414002627
VISIT DATE: 11/16/2023
NARRATIVE
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LPA reviewed 10 children's files and one helper's files. LPA observed all children's files to be complete. Children's files all included LIC282, LIC627, LIC700, LIC995A, and immunization records for all children who are not school-age. LPA observed that helper's file is incomplete. LPA advised Licensee to obtain all required licensing documents for helper. LIC126 (Entrance Checklist) was provided to Licensee as a reference for all required documentation.

LPA observed detergents to be present in the back of the kitchen, a licensed day care area. Licensee removed detergents and placed them in an area inaccessible to children in an off-limits area. Additionally, LPA pointed out a power tool that was left in the playroom area. Licensee promptly removed the tool and placed it in an off-limits area.

LPA discussed Mandated Reporter Training and the requirement to renew the training every two years. Licensee understands the requirement to complete the training for all staff.

There is one helper who is not associated to the facility. They have been fingerprinted and Licensee has been in contact with Guardian regarding steps to correct any errors in the fingerprinting process. LPA reminded Licensee of requirement to have all adults living or working in the home fingerprinted and associated to the facility.

LPA discussed emergency drill logs with Licensee, and Licensee stated that they would begin to document logs with a central document that will be posted.

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

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
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 CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: RUSSELL, CARRIE J.
FACILITY NUMBER: 414002627
VISIT DATE: 11/16/2023
NARRATIVE
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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.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514- 0383 (TTY) and link to publication: Commonly Asked Questions about Child
Care Centers and the ADA are available at: https://www.ada.gov/resources/child-carecenters/.

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.

See LIC809-D for deficiencies cited today. See LIC9102-TV for technical violations cited today.

A notice of site visit was given and must remain posted for 30 days. Appeal rights were reviewed and given to Licensee.

Exit interview conducted and report was reviewed with the licensee, Carrie Russell.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
LIC809 (FAS) - (06/04)
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