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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414005148
Report Date: 09/12/2024
Date Signed: 10/08/2024 11:33:15 AM

Document Has Been Signed on 10/08/2024 11:33 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:AHMADOVA, GULSUMFACILITY NUMBER:
414005148
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
09/12/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:09 AM
MET WITH:Gulsum AhmadovaTIME VISIT/
INSPECTION COMPLETED:
01:10 PM
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On September 12, 2024, @ approx. 9:10am, Licensing Program Analyst (LPA)Maria Olguin-Leon conducted an announced, pre-licensing inspection visit. LPA met with applicant, Gulsum Ahmadova and explained the purpose of the inspection. Applicant submitted a small childcare home application to our department on August 20, 2024. Hours of operation will Monday-Friday from 8:00am to 5:30pm. Applicant plans to provide care to children ages 0 months to 4 yrs. old. Present during today’s visit was applicant and adult son and no children. As of today, only applicant is living in the home.

With applicant, LPA inspected the indoors and outdoors of the home for health and safety hazards. Home is a tri-level home with 4-bedroom 3-bathroom. Lower level (main daycare area) consists of main room, bathroom #1, bedroom #1 (napping room), garage, 2nd level consist of living room, dining room, kitchen, entrance hall (foyer), 3rd level consist of bedrooms #2, #3 and #4, bathroom #2, and master bathroom. The DAY CARE AREAS: are entrance hall foyer, main room, bedroom #1, bathroom #1 and backyard. The OFF-LIMIT AREAS garage, living room, dining room, kitchen and entire 3rd level. Applicant was notified any off-limit areas are not to be used as a day care area without prior approval from department. Applicant understand applicant will need to be on the same floor where children are napping.

LPA observed the following: Home was clean and orderly. Main room (daycare room) is equipped with plenty of age-appropriate toys, learning materials, toy storage cubbies, children’s cubbies, and rugs to cushion falls. Napping room is equipped with a crib, children’s beds, and a changing table. Applicant will provide sheets for crib and beds and applicant will wash weekly or as needed. Bathroom is equipped with a training potty seat and toiletries for children. Fireplace located in living room is properly barricaded with a fireplace screen. All electrical outlets are properly covered with child proof covers and furniture. There is child proof gate located at lower-level staircase. Backyard is equipped with a gazebo for shade and a children’s table. Gazebo has cement flooring and a rug and a portion of the backyard consist of dirty/dry grass. There are blue foam mats installed at exit door into backyard to cushion falls. There is a 5 ft. fence surrounding entire backyard. LPA did not observe spas, pools, or other bodies of water.

Cont. page 2...
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Maria Olguin-Leon
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2024
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 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: AHMADOVA, GULSUM
FACILITY NUMBER: 414005148
VISIT DATE: 09/12/2024
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Home has proper ventilation and lighting throughout. Per applicant, off-limit areas will remain closed and locked during operating hours. All detergents, cleaning compounds, medications and other items which could pose a danger are stored inaccessible to children and/or located in off limit areas. Per applicant, there are no weapons or firearms in the home. Applicant plans to carry liability insurance.

Home is equipped with working smoke detector, working carbon monoxide detectors, and three 2-A:10BC fire extinguisher, one is stored in playroom. Applicant uses a designated cell phone and is aware the cell phone must stay within the home during the day care hours. Isolation area for sick children will be in hallway area on lower level and away from other children and where applicant can supervise all children in care. Applicant will educate and explain to children proper behavior for discipline.

LPA reviewed the LIC311D, Records to Keep in Your Family Child Care Home, children’s forms/ records, facility forms, and information to be posted. Entrance Checklist was provided to the applicant. Applicant’s CPR/First Aid certification is current and will expire 07/2026. Applicants Mandated Reporter training certificates (AB1207) is current that will expire 07/2026. LPA observed a full stocked first aid kit.

LPA and applicant discussed licensing regulations and the capacity requirements. Any children under 10 years of age that live in the home, will be counted in overall capacity. Applicant plans to provide two meals and two snack to children in care. LPA discussed sanitation and allergies with applicant. LPA reminded Applicant to label all food brought from home.

Applicant understands the required emergency disaster drills are to be conducted and documented at least once every six months. Applicant understands that the use of baby walkers, bouncers, jumpers, and similar items are not to be used for children in care. Smoking is prohibited inside a Family Childcare Home.

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SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Maria Olguin-Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
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: AHMADOVA, GULSUM
FACILITY NUMBER: 414005148
VISIT DATE: 09/12/2024
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Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

The applicant provided proof of control of property.

The applicant has not obtained a signed Property Owner/Landlord Consent form (LIC9149). Without this consent, the applicant understands that, once licensed, they can operate with a maximum capacity of 6 [or 12] children. If property owner/landlord consent is obtained in the future, the applicant is advised that a new Application for a Family Child Care Home License (LIC 279) must be submitted with a change of capacity fee of $25, to increase the capacity and provide care to 8 [or 14] children.

This facility plans to provide Incidental Medical Services – IMS. For IMS information, see PIN 22-02-CCP. 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 applicant and discussed the Child Care Licensing Safe Sleep webpage at: https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep, as an additional resource. LPA also informed [applicant, licensee, or facility representative] 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.

Cont. page 4...
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Maria Olguin-Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
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 CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: AHMADOVA, GULSUM
FACILITY NUMBER: 414005148
VISIT DATE: 09/12/2024
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On this date, 08/21/2024, 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.

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 platforms. 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

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

Prior to licensure, following is to be completed:

-Install childproof gate on staircase and at entrance into living room
-Childproof locks on bathroom cabinet and main room cabinets
-childproof locks on lower-level closets
-Post all required licensing documents
-submit signed letter for adult not living in home

Applicant will send LPA photos, once completed.

Exit interview conducted and report was reviewed with the applicant, Gulsum Ahmadova; adult son Musa Huseynzade translated report to applicant in Azerbaijani. Applicant is also fluent in Russian.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Maria Olguin-Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
LIC809 (FAS) - (06/04)
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