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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414002627
Report Date: 12/06/2023
Date Signed: 12/06/2023 04:20:27 PM

Document Has Been Signed on 12/06/2023 04:20 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: 14DATE:
12/06/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Licensee's Husband, Thomas German (H1)TIME COMPLETED:
04:25 PM
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
On 12/6/2023, at approximately 3:45PM, Licensing Program Analyst (LPA) Jonathan Tse conducted an unannounced POC visit at the facility. LPA was granted entry to the facility by Licensee's husband, Thomas German. Present in the facility was Thomas German (H1), a helper (H2), two preschool age children, and 12 school-age children. The facility is in compliance with capacity requirements on this day. Per H1, Licensee is not present during today's visit due to a doctor's visit.

During LPA's prior visit to the facility on 11/16/2023, LPA had cited the facility for: having harmful or dangerous materials in the presence of children in care, incomplete Mandated Reporter Training, and an un-fingerprinted helper (H3) present in the home. Licensee had removed the potentially harmful materials from the daycare areas during the visit and the deficiency was cleared the same day. A Plan of Correction (POC) was developed with Licensee, and instructions on how to proceed were discussed. Licensee had maintained communication with LPA over the course of completing the POC.

Licensee had submitted proof of completion of Mandated Reporter Training to LPA. LPA verified that Licensee had completed the correct Child Care Provider's training. Deficiency will be cleared on this day.

Licensee had sent H3 to get fingerprinted and associated after LPA's visit on 11/16/2023. Upon record review of the fingerprint status, LPA verified that H3 had been fingerprinted and acquired CA, FBI and CACI clearance as of 8/31/2023. H3 was fingerprinted again and is now associated to the facility. H3 is not present in the facility as of this day. Deficiency will be cleared on this day.

A Letter of Deficiencies Cleared, in addition to this report, will be given to H1 and emailed to Licensee.
A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with H1, Thomas German.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2023
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 1