384002616-3-2-2022-05-CC-CQUO-CC5SSR-20220302130822

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 384002616
Report Date: 03/02/2022
Date Signed: 03/02/2022 01:08:55 PM

Document Has Been Signed on 03/02/2022 01:08 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	LEETZ, PETER		FACILITY NUMBER:	384002616
ADMINISTRATOR:	LEETZ, PETER		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(415) 886-5968
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94131
CAPACITY:	14	CENSUS: 12	DATE:	03/02/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Peter Leetz		TIME COMPLETED:	12:40 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 March 2, 2022 at 9:00am, Licensing Program Analyst (LPA) Catrina Quimbo conducted an unannounced, annual inspection. LPA met with licensee, Peter Leetz. Present during inspection was licensee, licensee's spouse, 3 helpers (H1, H2, and H3), and 12 enrolled children (2 infants and 10 preschool age). Licensee is operating within capacity limits and ratio requirements on this date. All adults living and/or working in the home have criminal record clearance on file. Hours of operation are Monday to Friday from 8:00am to 5:00pm. Licensee rents the multi-level home that includes three levels. Family child care home operates on the second level (main level) of the home. The DAY CARE AREAS are living room, playroom/nap room, bathroom, kitchen, dining room, and backyard area. The OFF-LIMIT AREAS are the entire third level and ground level (garage and in-law unit). All off limit areas are barricaded with child safety locked doors and/or child safety gates. At approximately 9:15am, LPA toured day care areas of home with licensee. LPA observed home to be in good repair with proper temperature and ventilation. Day care operates as a German/English Immersion program. There were a variety of age appropriate toys and equipment that were in good condition. All accessible electrical outlets are covered with child safety covers. Home has multiple windows with child safety lock stoppers. Outside area does not include any pools, spas or bodies of water. The entire backyard is enclosed with an least 5 ft. high fence. LPA observed backyard to have age appropriate equipment that were in good working condition. All cleaning supplies, poisons and other chemicals were stored inaccessible to children in home's high shelves and/or behind child safety locked cabinets. (Continue on Page 2....)

SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

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 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: LEETZ, PETER	FACILITY NUMBER: 384002616
	VISIT DATE: 03/02/2022

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
26
27
28
29
30
31
32

(Continued, Page 2...)
Home has multiple smoke and carbon monoxide detectors and fully charged fire extinguisher. Phone number listed for licensee is current. Per licensee's spouse, there are no weapons or firearms in the home. LPA reviewed all enrolled children's files which were complete. Children's files have a record of emergency identification information on file. LPA reviewed licensee, H1, H2, and H3's files which were complete. Licensee has records of immunizations on file. Multiple helpers present in the home have valid Pediatric First Aid/CPR certificates that are current. Licensee’s Pediatric First Aid/CPR is current and will expire 01/2024. Emergency drills are conducted at least once every six months and are properly logged. Last emergency drill conducted was 01/12/2022.

During Inspection:
- Licensee was given information regarding PIN 20-24-CCP Safe Sleep Regulation and Lead Poisoning Facts Flyer.
-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.
-Licensee was reminded about Mandated Reporter training available on CCLD website. Training must be completed every 2 years by all staff hired. Training can be taken online at www.mandatedreporterca.com.
-Licensee was reminded about the Provider Information Notices (PINs) on CCLD website.
-Licensee was advised for any additional questions to contact CCLD office, Monday to Friday, 8:00am - 5:00pm, (650) 266-8800 or 1 (844) 538-8766. Website: www.cdss.ca.gov.

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 Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (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

(Continue Report on Page 3...)

SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: LEETZ, PETER	FACILITY NUMBER: 384002616
	VISIT DATE: 03/02/2022

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
26
27
28
29
30
31
32

(Continue, Page 3...)
To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

Licensee 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.

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-and-resources/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.

No deficiencies were cited today under CCR, Title 22, Div. 12.

A notice of site visit was given and must remain posted for 30 days.

An exit interview conducted and report was reviewed with the licensee, Peter Leetz.

SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3