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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214005441
Report Date: 04/12/2022
Date Signed: 04/12/2022 12:31:32 PM

Document Has Been Signed on 04/12/2022 12:31 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:STIFFLER, SHARON A.FACILITY NUMBER:
214005441
ADMINISTRATOR:STIFFER, SHARON A.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 459-1219
CITY:SAN ANSELMOSTATE: CAZIP CODE:
94960
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 12DATE:
04/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Licensee, Sharon StifflerTIME COMPLETED:
12:40 PM
NARRATIVE
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On April 12,2022 at 10am, Licensing Program Analyst (LPA) Kassandra Medrano conducted an annual required inspection which included a toured the home and yard, and a review of the required day-care forms with the licensee today. Present in the home is Licensee, 3 helpers and 12 preschool age. Capacity and ratio requirements of children was observed in compliance today. This type of home is a single family, two story home. Off limit rooms were identified as Kitchen. At 10:20am during review of records LPA indicated that there was an uncleared individual assisting with the children. LPA questioned licensee about staff, and stated that she typically comes in the last hour to clean, but today was the first day licensee had her in ratio. Licensee is aware that all adults working or living in the home who require caregiver background checks must receive criminal record and child abuse index clearances or exemptions. 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 due to this regulation being violated. Staff that was uncleared was immediately asked to leave facility, and will not return until they are fingerprinted. Licensee owns home. The day-care operates 8am-5:30pm, Monday through Friday. Licensee does not have day-care insurance parent’s sign the affidavit. LPA observed the following: Stairs in the home are properly barricaded at top/bottom if caring for children under five years old. Day-care area is clean, orderly, and equipped with age appropriate toys and equipment for the children. No baby walkers, bouncers, exercausers, etc. allowed to be used during day-care hours. Home has proper lighting and ventilation. Home has a working telephone, a working smoke and carbon monoxide detector, and a fully charged 2A10BC fire extinguisher. Licensee states there is a hot tub in yard, but it is covered, and children do not play in that space. There is not a fireplace in the day-care area.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Kassandra Medrano
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2022
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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: STIFFLER, SHARON A.
FACILITY NUMBER: 214005441
VISIT DATE: 04/12/2022
NARRATIVE
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There are no detergents, or cleaning products accessible to day-care children. Poisons are locked. Licensee states there are no guns or weapons of any kind in the home. The yard is fenced. Licensee states there are pets in the home: one cat. Vaccinations are current. At 10:30am during file review, Licensee stated that CPR has expired, but could not provide card with expiration. During the same staff file review, LPA observed that both staff were missing documentation of immunization's. Emergency drills are conducted at least once every six months and properly logged. Licensee provide daily snacks, and parents provide meals. Isolation of sick children reviewed/discussed. Children’s roster was reviewed and is complete and up-to-date. Children and staff/helper files were reviewed and are complete. Supervision and transportation of children was discussed. Capacity options were reviewed. Licensee understands that care cannot be provided for more than the capacity as stated on the license. Requirements for reporting suspected child abuse was discussed, as well as reporting requirements for unusual incidences. All required postings are properly posted (License/Parent’s Rights poster/Emergency Disaster Plan and Earthquake Preparedness Checklist) Licensee has updated immunization's and Mandated Reporter Training on file. But, staff were missing documentation of mandated reporter training. Licensee was reminded that as of September 1, 2016, a person may not be employed or volunteer at a child care 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. Licensee was informed about the Provider Information Notices (PINs) on CCLD website. Licensee was reminded about Mandated Reporter Training available on CCLD website (www.ccld.ca.gov or www.mandatedreporterca.com). 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. At 11am, during review of infant files, LPA observed that sleeping logs were missing. 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 issued today under Title 22 Division 12 of the California Code of Regulations. This report and appeal rights were discussed with Licensee. This report must be available in the facility for public review. Notice of Site Visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee, Sharon. 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/inspection-process.

This Type A citation page shall be posted for 30 days along with the Notice of Site Visit. This page shall be provided to all parents of children currently enrolled and any future children being enrolled for the next 12 months per AB 633 requirements.

SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Kassandra Medrano
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 04/12/2022 12:31 PM - It Cannot Be Edited


Created By: Kassandra Medrano On 04/12/2022 at 12:02 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: STIFFLER, SHARON A.
FACILITY NUMBER: 214005441

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102370(d)(1)
Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above, present in the facility there was one uncleared individual which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/12/2022
Plan of Correction
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Licensee immediatley removed uncleared individual, and stated she will not return until she receives fingerprint clearance.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Ali Zebila
LICENSING EVALUATOR NAME:Kassandra Medrano
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 04/12/2022 12:31 PM - It Cannot Be Edited


Created By: Kassandra Medrano On 04/12/2022 at 12:02 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: STIFFLER, SHARON A.
FACILITY NUMBER: 214005441

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above, 2 of the staff files were missing documentation of immunizations. Which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2022
Plan of Correction
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Licensee states she will have staff provide documentation of immunizations, and or declination of flu shot.
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above, licensee stated that she has not updated her CPR. Which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/31/2022
Plan of Correction
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Licensee to send proof of completion or registration if she cannot complete within the timeframe.
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:Ali Zebila
LICENSING EVALUATOR NAME:Kassandra Medrano
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022


LIC809 (FAS) - (06/04)
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