414004884-4-14-2023-05-CC-MROZ-CQW3RW-20230414182924

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414004884
Report Date: 04/14/2023
Date Signed: 04/14/2023 06:29:34 PM

Document Has Been Signed on 04/14/2023 06:29 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 CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	EMPIRE INFANT		FACILITY NUMBER:	414004884
ADMINISTRATOR:	SARAH JEN		FACILITY TYPE:	830
ADDRESS:	3080 LA SELVA STREET		TELEPHONE:	(650) 678-3638
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94403
CAPACITY: 20	TOTAL ENROLLED CHILDREN: 18	CENSUS: 14	DATE:	04/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Sarah Jen and Bonnie Li		TIME COMPLETED:	06:45 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	Licensing Program Analyst (LPA) Marie Rodriguez conducted an unannounced annual inspection. LPA met with Director Sarah Jen and explained purpose of inspection. Center has an infant program and a preschool program under license #414004883. Present in the infant center were the Director, two teachers, and 14 infants. Facility representative Bonnie Li arrived awhile later. Center is operating within capacity requirements but is not in compliance with child to staff ratio. Hours of operation are Monday to Friday from 8:00am to 6:00pm. LPA inspected the infant classroom (classroom 3) and outdoor play area with Director. There are no bodies of water, firearms, or weapons on the premises. The center is in good repair with proper temperature and ventilation and is free of any hazards. All furniture is in good condition. Classroom has age appropriate toys and equipment. Room has a separated area designated for napping. Napping equipment includes mats and cribs which are in good condition. Mats are properly stored when not in use. A first aid kit is available in the classroom. All cleaning products and toxins are inaccessible to children. Outdoor play area is fenced for supervision. The outdoor toys and equipment in the play area are age appropriate and in good condition. All required postings are properly posted in the bulletin board in front of the center. Center provides a hot lunch and morning and afternoon snacks. Lunch is cooked in-house by staff. Food prep area is clean and free of any toxins or contamination. All food is properly stored to avoid contamination. All storage containers for solid waste have a proper lid. Infant classroom shares a bathroom with classroom 3. Bathroom area has five toilets and five sinks for children use with additional potty chairs. Bathroom area appears to be clean, in good repair, and free of any hazards. There is a separate bathroom for staff usage on the premises. There is a changing table and a sink for staff to wash their hands. Changing area is kept clean, in good repair, and maintained with adequate supplies. Changing table is disinfected after every use.

SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Marie Rodriguez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

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 04/14/2023 06:29 PM - It Cannot Be Edited

Created By: Marie Rodriguez On 04/14/2023 at 04:21 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: EMPIRE INFANT	FACILITY NUMBER: 414004884
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

101416.5(b)

Staff-Infant Ratio

(b) There shall be a ratio of one teacher for every four infants in attendance. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above due to there only being 3 teachers supervising a total of 14 infants which poses an immediate health and safety risk to infants in care.
	POC Due Date: 04/17/2023
	Plan of Correction
1 2 3 4	Facility represenative will ensure to comply with staff to infant ratio of 1:4 and will provide LPA with a record to show infants and staff present on April 17, 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:

Daniel J Oquendo

LICENSING EVALUATOR NAME:

Marie Rodriguez

LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 04/14/2023 06:29 PM - It Cannot Be Edited

Created By: Marie Rodriguez On 04/14/2023 at 04:21 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: EMPIRE INFANT	FACILITY NUMBER: 414004884
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101174(d)

Disaster and Mass Casualty Plan

(d) Disaster drills shall be conducted at least every six months. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. Last emergency drill was conducted on March 18, 2022 which poses a potential health and safety risk to infants in care.
	POC Due Date: 04/21/2023
	Plan of Correction
1 2 3 4	Facility will conduct an emergency drill and provide LPA with the log showing it has been completed by the POC due date.

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:

Daniel J Oquendo

LICENSING EVALUATOR NAME:

Marie Rodriguez

LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

LIC809 (FAS) - (06/04)

Page: 3 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 CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: EMPIRE INFANT	FACILITY NUMBER: 414004884
	VISIT DATE: 04/14/2023

NARRATIVE

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Last emergency drill was conducted on March 18, 2022. Sign-in/out sheets are done electronically. The center has a complete electronic record of sign-in/out sheets by authorized pickup person. There is a working fire alarm system and sprinkler system throughout the center. There is a working smoke and carbon monoxide detector, a fully charged fire extinguisher, and a working telephone available on-site.

Ten children records were reviewed and complete. All children have a record of emergency identification information on file. Each child has an individual infant safe sleep plan in file.

Deficiencies cited today under California Code of Regulations, Title 22, Division 12, which follows on LIC 809-D.

LPA Marie Rodriguez informed facility representative Bonnie Li that this report dated April 14, 2023 document(s) 1 Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Marie Rodriguez informed the facility representative to provide a copy of this licensing report dated April 14, 2023 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

An annual continuation will be completed at a later date.

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.

Exit interview was conducted and report was reviewed with Facility Representative Bonnie Li. Appeals Rights was given to facility representative.

SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Marie Rodriguez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

LIC809 (FAS) - (06/04)

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