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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214005278
Report Date: 10/26/2021
Date Signed: 11/23/2021 12:54:50 PM

Document Has Been Signed on 11/23/2021 12:54 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:MAJOULET, HEATHERFACILITY NUMBER:
214005278
ADMINISTRATOR:MAJOULET, HEATHERFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 225-5770
CITY:NOVATOSTATE: CAZIP CODE:
94949
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 10DATE:
10/26/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:16 PM
MET WITH:Heather MajouletTIME COMPLETED:
04:30 PM
NARRATIVE
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On 10/27/21 at 3:16PM, Licensing Program Analyst (LPA) Haydee Caliboso conducted a 10-day complaint inspection in response to allegation received on 10/21/21. LPA met with the Licensee, Heather Majoulet and explained the purpose of the inspection. Present during the inspection was the Licensee, Assistant Teacher, 5 school-age children, and 5 preschool children.

During the course of inspection and record review, the Licensee did not have children’s records and documents in file and available during the inspection.

>See 809-D for deficiencies issued today under Title 22 Division 12 of the Ca. Code of Regulations.

>This report and rights to comment and appeal were discussed with Licensee. This report must be available in the facility for public review. Notice of site visit was observed being posted.
Licensee was advised any additional questions to call Office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website: www.cdss.ca.gov
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Haydee R Caliboso
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2021
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 11/23/2021 12:54 PM - It Cannot Be Edited


Created By: Haydee R Caliboso On 10/27/2021 at 12:27 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: MAJOULET, HEATHER
FACILITY NUMBER: 214005278

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/09/2021
Section Cited
CCR
102421(a)(1)

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102421: Child's Records

(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).
(1) The licensee shall keep the signed and dated notice form for at least three years following termination of service to the child.
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Licensee will have all the chlidren's records complete and available in file upon request by 11/9/21.
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This requirement is not met as evidence by: file review, LPA Haydee Caliboso observed there was no file for an individual child who is present today. This is a potential health and safety risk to children in care.
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The licensee has obtained and provided all the documents needed to be kept in file for each children.

The deficiency is cleared.

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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:Cindy Interiano
LICENSING EVALUATOR NAME:Haydee R Caliboso
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2021


LIC809 (FAS) - (06/04)
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