414002790-11-27-2023-05-CC-MTSO-CXYR3G-20231127113955

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414002790
Report Date: 11/27/2023
Date Signed: 11/27/2023 11:40:10 AM

Document Has Been Signed on 11/27/2023 11:40 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:	JENSEN, THERESA MARIE		FACILITY NUMBER:	414002790
ADMINISTRATOR:	JENSEN, THERESA MARIE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(650) 296-9625
CITY:	PACIFICA	STATE: CA	ZIP CODE:	94044
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 9	DATE:	11/27/2023
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME BEGAN:	08:21 AM
MET WITH:	Theresa Jensen		TIME COMPLETED:	11:45 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	On November 27, 2023, Licensing Program Analyst (LPA) Tso conducted an unannounced, annual visit to the Family Child Care Home listed above. The LPA was granted entry by the Licensee, Theresa Jensen. LPA explained the purpose of the visit. Present during LPA's visit included licensee, licensee's spouse and 9 enrolled children (preschool age). The license is operating within capacity limits and ratio during LPA's visit. Licensee lives in a 2-bedroom home with the spouse and an adult daughter. All adults living in the home have fingerprint clearance on file. The hours of operation are Monday – Friday, 8:00 AM to 5:00 PM. The Day-care areas are: Living Room, Dining Room, Bathroom, and Back Yard. The rest of the home is off-limits. Off limit areas are properly barricaded with closed doors. The LPA and the licensee both performed careful inspections of the daycare facility to look for any potential health and safety hazards. Toys and equipment that are suitable for children of the proper age range are provided at the daycare. The building has sufficient lighting and ventilation, and it is free of any defects or conditions that put children at risk. The facility is equipped with a first aid kit that is completely loaded with everything that is required for the treatment of injuries. The daycare facility is equipped with a combined smoke and carbon monoxide detector, and a fire extinguisher that is always ready for use. Every garbage can and power outlet has been covered. LPA observed that the stove switches are not installed with childproof knobs. The licensee took out the switches immediately. LPA advised the licensee that the switches should be out of children's access to turn on the fire. (Technical Violation is issued.) Products for cleaning and washing, detergents, and any other materials that could put children in danger are stored out of the children’s reach. The LPA did not find any walkers, bouncers, or other comparable objects during today’s inspection. According to the licensee, there are reportedly no firearms or other weapons on the premises. The LPA observed that the facility has a plastic bucket for water collection in the backyard filled up water and locked with a lip. (Continue Report on Page 2...)

SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Man Tso
LICENSING EVALUATOR SIGNATURE:	DATE: 11/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/27/2023 11:40 AM - It Cannot Be Edited

Created By: Man Tso On 11/27/2023 at 10:18 AM

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: JENSEN, THERESA MARIE	FACILITY NUMBER: 414002790
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/27/2023

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
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in. The licensee's Mandated Reporter Training Certificate was expired, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/14/2023
	Plan of Correction
1 2 3 4	The licensee must complete the Mandated Reporter Training bi-annually and are available for review during the inspection. The licensee must complete the training and send the completion to the Licensing office by December 14, 2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Man Tso

LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023

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: JENSEN, THERESA MARIE	FACILITY NUMBER: 414002790
	VISIT DATE: 11/27/2023

NARRATIVE

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The LPA observed that the facility had not posted all the required forms, including the facility license, Notification of Parental Rights and Earthquake Preparedness Checklist. LPA reminded the licensee to post back at the entrance that used for dropping off and pick up children. (Technical Violation is issued.) The Licensee is aware that smoking is not permitted in a family childcare facility.

Bathroom for children's use was observed to be in proper working condition. LPA did not observe any hazardous materials to be accessible to children. Entire backyard is fully enclosed and fenced. Outdoor area is equipped with a variety of toys and materials. There is a play structure in the backyard that was observed to be in good condition. Flooring in backyard includes grass that was observed to be clean.

LPA reviewed five children’s records. Children’s files have a record of emergency identification information on file. Licensee's Pediatric First Aid/CPR is current and will expire 05/2025. Emergency drills are properly logged and maintained. Last emergency drill was conducted 10/26/2023. Licensee has licensing documentation available for review.

LPA reminded licensee about Mandated Reporter training available www.mandatedreporterca.com. Licensee was reminded Mandated Reporter training must be renewed every 2 years and all staff whom directly work with children must complete training. The Mandated Reporter training certificate of the licensee was expired on 6/13/2023 (Please refer to LIC 809D).

Licensee was reminded, as of September 1, 2016, all Staff and Volunteers must provide proof of immunization against pertussis, measles, and influenza, or qualifies for an exemption, pursuant to Health and Safety code 1596.7995 and 1597.622.

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.
(Continue Report on Page 3...)

SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Man Tso
LICENSING EVALUATOR SIGNATURE:	DATE: 11/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4

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: JENSEN, THERESA MARIE	FACILITY NUMBER: 414002790
	VISIT DATE: 11/27/2023

NARRATIVE

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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.

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, the licensee, Theresa Jensen, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Please refer to LIC 809D for today’s citation. A copy of today’s report and the facility’s appeal rights were given to Theresa Jensen. The Notice of Site Visit was given to Theresa Jensen and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Exit interview conducted and report was reviewed with Theresa Jensen.

SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Man Tso
LICENSING EVALUATOR SIGNATURE:	DATE: 11/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023

LIC809 (FAS) - (06/04)

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