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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414001599
Report Date: 06/26/2024
Date Signed: 06/26/2024 07:03:14 PM

Document Has Been Signed on 06/26/2024 07:03 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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:ZACK, JERBANU PERVEZFACILITY NUMBER:
414001599
ADMINISTRATOR/
DIRECTOR:		ZACK, JERBANUPERVEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 627-8418
CITY:FOSTER CITYSTATE: CAZIP CODE:
94404
CAPACITY: 14TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
06/26/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Jerbanu ZackTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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On June 26, 2024, at approximately 8:40am, Licensing Program Analyst (LPA) Maria Olguin-Leon conducted an unannounced annual inspection and met with licensee Jerabanu Zack, and purpose of inspection was explained. Licensee was closed this week to reorganize and set up for summer session, no daycare children were present today. Licensee granted LPA entry. Present during today’s visit was Licensee, Licensee spouse, licensee’s adult daughter/helper and minor grandchild. Facility hours of operation are Monday - Friday from 8:30AM to 5:30PM.

LPA and Licensee toured the home for health and safety hazards. Home is a two-level story home. Day Care Areas: Living room (main classroom), dining room, downstairs bathroom, and outdoor patio. Off Limits Areas: Second floor, kitchen, and garage. Isolation area for ill children will be in living room and away from other children. LPA observed home to be clean and orderly. Home is well light and has proper ventilation. LPA observed electrical outlets are secured with child proof covers. Kitchen area and staircase are equipped with a child proof gate for inaccessibility to children in care. Cleaning supplies and other potentially harmful items are stored inaccessible to children. There are plenty of age-appropriate toys, books, child size furnishings, learning material, and sleeping mats. Patio is equipped with artificial grass and a rug to cushion falls. Patio has age-appropriate toys which include a playhouse, basketball court, sand/water table and slide play structure all in good condition. Patio is surrounded with a 5 ft. fence. LPA did not observe any spas, pools, or other bodies of water.

Home is equipped with a working carbon monoxide detector and working smoke detector. A fully charged fire extinguisher is located in kitchen. LPA reviewed first aid kit and kit is fully stocked. Licensee has a landline and uses a cell on the premises. Per licensee, there are no weapons or firearms in the home. Parents provide sheets for sleeping mats and are sent home weekly for laundering.

Cont. page 2…
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Maria Olguin-Leon
LICENSING EVALUATOR SIGNATURE: DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/26/2024
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 3
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: ZACK, JERBANU PERVEZ
FACILITY NUMBER: 414001599
VISIT DATE: 06/26/2024
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LPA reviewed 5 children’s files and 1 staff file. All files were complete with all required documents. Licensee carries liability insurance via Markel Insurance which is effective 03/2024. Licensee maintains an updated Children’s roster. Licensee CPR/First Aid is current and expires 02/2025. Licensee Mandated Reporter training expires 04/2025. Licensee provides meal to children in care, which includes two snack and lunch. LPA observed Childcare License, Emergency Disaster Plan (LIC610A) and Parent's rights posted. Last emergency drill was conducted on March 12, 2024, and is properly documented.

Licensee was reminded that all adults 18 and over living or working in the home, 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.

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)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

The Licensee was reminded about the Provider Information Notices (PINs) on the CCLD website. Licensee was informed 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. LPA's reviewed AB 1207 with the Licensee.

As of January 1, 2018, all staff must complete Mandated Reporter Training every two years. LPA reminded licensee about Mandated Reporter training available www.mandatedreporterca.com

Cont. page 3...
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Maria Olguin-Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2024
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: ZACK, JERBANU PERVEZ
FACILITY NUMBER: 414001599
VISIT DATE: 06/26/2024
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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. LPAs also informed licensees 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.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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

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

During the exit interview, the LICENSEE, Jerbanu Zack confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.



No deficiencies were issued today under Title 22 Division 12 of the California Code of Regulations.

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

Exit interview conducted and report was reviewed with the licensee, Jerbanu Zack.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Maria Olguin-Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2024
LIC809 (FAS) - (06/04)
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