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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414005141
Report Date: 10/25/2024
Date Signed: 10/25/2024 11:51:50 AM

Document Has Been Signed on 10/25/2024 11:51 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:GUSTAVSON, DANIELLE R.FACILITY NUMBER:
414005141
ADMINISTRATOR/
DIRECTOR:
GUSTAVSON, DANIELLE R.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 515-9618
CITY:PACIFICASTATE: CAZIP CODE:
94044
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
10/25/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Danielle R GustavsonTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On October 25th 2024, at approximately 9:30 AM., Licensing Program Analyst (LPA) Janet Gil conducted an announced pre-licensing inspection and met with the Applicant, Danielle R Gustavson. LPA was granted entry by the applicant. LPA explained the purpose of the visit to the applicant. No children were present today.

The applicant living in the home does not have cleared a background check. Per applicant, she will be re- doing her fingerprints on 10/28/2024. Applicant was reminded that she can not operate or be licensed without background check clearance. Applicant owns this multi level home consisting of two living rooms, 3 bedrooms, 3 bathrooms, a kitchen, attached garage, lower level art room and a backyard space. The residents of the home are the Applicant and three children. Days and hours of operation will be Monday - Friday, 12:00 PM to 5:00 PM.

Day Care Areas: Play Room(living room 1), Children's Bathroom, Bedroom 1, Lower Level Art Room, Front Yard, and Backyard. Per applicant, she plans to utilize Bedroom 1 as an isolation for sick/ill children.

Off-limit Area: All Upstairs area(2 bedrooms, 2 bathrooms), Kitchen and Garage. Side Yard is walk through only.

At approximately 9:40 AM, LPA, and the applicant inspected the entire home for Health and Safety Hazards. The home is clean and orderly and has sufficient lighting and ventilation. There are a variety of age-appropriate toys and books for children. Applicant plans to run a Part Time School Age Program in her home. Per Applicant, no nap time will be offered due it program being school age. All furniture and playthings were observed to be in repair. The facility has a carbon monoxide detector near kitchen area. LPA tested detector which was observed to be in working condition. First Aide Kit is located in hallway closet near the children's bathroom. All harmful objects, sharp objects, and toxins are stored in higher shelves of closet next to children's bathroom area inaccessible to children. Per applicant, there is two pet cats in the home, and both have required immunization.

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SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Janet Gil
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2024
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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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: GUSTAVSON, DANIELLE R.
FACILITY NUMBER: 414005141
VISIT DATE: 10/25/2024
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Applicant states that the home has no weapons, firearms. All Electrical outlets have been covered by outlet covers or furniture in all Child Care areas of the home. LPA observed facility has a properly latched and covered hot tub that was made inaccessible to children. The backyard play area is enclosed and has age-appropriate toys for children. LPA observed a covered sandbox and built in play structure with grass underneath.

At approximately 10:40 AM, LPA informed the applicant that emergency drills are required every six months and must be documented. Applicant was reminded that NO baby walkers, exer-saucers, jumpers, bouncers, and any similar items to be used for children in care and should be made inaccessible. In addition, booster chairs are only used for the purpose of feeding/eating. Per applicant, she plans to provide snack only for the children in care. Applicant plans to have children's parents or representatives provided lunches. The applicant was also reminded that smoking is prohibited at the day-care.

Per applicant, she plans to provide care to school age children only. Per applicant, she has purchased liability insurance for childcare. LPA informed applicant that if childcare insurance is not purchased, each parent must be given the Affidavit Regarding Liability Insurance for Family Child Care Home (LIC 282). Applicant’s Pediatric First Aid CPR expires on 8/2025. Copy of certificate has been submitted to the Department. Applicant has not completed Mandated Reporter Training. Applicant was reminded that both certificates expire in two years.

LPA reviewed with the Applicant the LIC 311D; Forms/Records to Keep In Your Family Child Care Homes, children's forms/records, facility forms/records, and all required postings such as License/Parent's Rights poster/Emergency Disaster Plan and Earthquake Preparedness checklist. In addition, the Entrance Checklist was also provided to the applicant. The applicant plans to have all the required posting on the wall next to his front door.

License capacity regulations were also reviewed with applicant. LPA informed the applicant that if care is provided for a 13th and 14th child, they must be school- aged, and parent notification and landlord consent is required. Applicant only plans to care for all school- aged children.

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SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Janet Gil
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC809 (FAS) - (06/04)
Page: 2 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: GUSTAVSON, DANIELLE R.
FACILITY NUMBER: 414005141
VISIT DATE: 10/25/2024
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Applicant was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.


The applicant provided proof of control of property.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. 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, available at: http://www.ada.gov/childqanda.htm.

LPA discussed the safe sleep regulations with the applicant and discussed the Child Care Licensing Safe Sleep webpage https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed applicant 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.

On this date, 8/2/2024, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

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SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Janet Gil
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
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: GUSTAVSON, DANIELLE R.
FACILITY NUMBER: 414005141
VISIT DATE: 10/25/2024
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Applicant was reminded that as of September 1, 2016, a person may not be employed or volunteer at a childcare facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662.

The Applicant was encouraged to obtain a copy of regulations and current licensing forms through the Department's website at www.ccld.ca.gov. The Applicant was also reminded of Mandated Reporter Online Training for Child Care Providers (AB 1207) and the additional General Training, and both are available on www.mandatedreporteca.com.

Applicant was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain childcare by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.

To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.


Prior to approval of Large Family Childcare: Danielle R Gustavson shall complete and submit verification of the following:

- Submit Mandated Reporter Certificate to LPA Gil

- Submit Proof of large fire extinguisher of 2A10:BC or greater

- Obtain Criminal Record Clearance

- Obtain Fire Clearance for large license

Exit interview conducted and report was reviewed with the applicant Danielle R Gustavson. The report was signed by the Applicant, Danielle R Gustavson and provided to him. This report will be kept in the facility file and available for public review upon request. Desk duty is available Monday - Friday, 8:00 AM – 5:00 PM (650) 266-8800. Website for Forms and Regulations: www.cdss.ca.gov.

SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Janet Gil
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC809 (FAS) - (06/04)
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