414002986-2-28-2025-05-CC-MZAA-DEBV6U-20250228151006

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414002986
Report Date: 02/28/2025
Date Signed: 02/28/2025 03:10:12 PM

Document Has Been Signed on 02/28/2025 03:10 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:	KOZACZUK, PETER		FACILITY NUMBER:	414002986
ADMINISTRATOR/ DIRECTOR:	KOZACZUK, PETER		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(650) 344-6925
CITY:	BURLINGAME	STATE: CA	ZIP CODE:	94010
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 12	DATE:	02/28/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:00 PM
MET WITH:	Licensee, Peter Kozaczuk		TIME VISIT/ INSPECTION COMPLETED:	03:30 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 February 28, 2025, at approximately 1:00pm, Licensing Program Analyst (LPA) Melissa Zaragoza conducted an unannounced, annual inspection. LPA was greeted and granted access by licensee’s spouse, Lilian Kozaczuk. At the entrance licensee was explained the purpose of the inspection. Present during LPA's visit included Licensee, licensee’s spouse, 1 staff, and 12 children (4 infants and 8 preschool age). Hours of operation are Monday through Friday. 8:00am to 5:00pm. Entrance to the facility is through side gate. Licensee lives in the multi-level home with their spouse. All adults living in the home and staff present, have fingerprint clearance on file. The DAY CARE AREAS are located on the first level of the home, that includes, bedroom #1 (napping room), bedroom #2 (not currently in use), garage (classroom), family room (eating area), bathroom #1, side of the home, and backyard. The OFF LIMIT AREAS are the entire second level of home, bathroom #2, and the guest house in backyard. Stairs in the backyard and stair to the main day care area are made inaccessible with child safety gates. LPA toured day care areas of home with licensee. LPA observed home to be in good repair with proper temperature and ventilation. Home is equipped with a variety of toys and materials that were observed to be in good condition. LPA observed electrical outlets to be made inaccessible with child safety covers. Cleaning supplies, poisons and hazardous materials are stored in home's high shelves and locked behind child safety locked cabinets. Home is equipped with a fully charged fire extinguisher and multiple smoke and carbon monoxide detectors. Smoke and carbon monoxide detectors were tested during visit and were observed to be in working condition. There are no pools, and bodies of water in the premises. (Continue Report on Page 2...)

SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Melissa Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025

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: KOZACZUK, PETER	FACILITY NUMBER: 414002986
	VISIT DATE: 02/28/2025

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...)
Napping room (bedroom#1) was observed to be equipped with playpens for napping children. Playpens were observed to be free of loose articles, bumper pads and pillows. LPA observed playpens to have mattresses with tight fitting sheets. LPA also observed cots for napping children. Per licensee, they provide the sheets and blankets, and sheets and blankets are washed weekly. Sleeping logs for napping infants are maintained and include the 15-minutes time check of when infant were last checked on.

Bathroom was observed to be in proper working condition. There is appropriate sanitation and toileting equipment for children in care. LPA observed children’s diapers and wipes in bathroom to be properly labeled with each child’s individual names. LPA observed a diaper changing area in the bathroom. Per licensee, children’s families provide diapers and wipes for enrolled children.

Children eat in the dining area. A food service is provided to children that includes breakfast, lunch and 2 snacks. LPA observed eating area to be clean and equipped with appropriate dining furniture. LPA observed cups for children, labeled with each individual child’s name on it. Per licensee, children are served water in their own cups. LPA observed knives to be made inaccessible.

Outdoor area is entirely enclosed and fenced. Outdoor area includes a variety of toys and equipment that were in good condition. Stairs in backyard were made inaccessible with a child safety gate. Garbage bins in backyard are also made inaccessible to children. LPA observed a shaded area in the backyard, for children. LPA did not observe any pools, spas or bodies of water on site.

LPA reviewed 6 random children's records which were complete. LPA reviewed licensee, licensee's spouse's and staff who were present records, which were complete. Licensee has a current CPR/First Aid certification and current Mandated Reporter certification. Licensee's CPR/First Aid certification will expire on 08/2026 and Mandated Reporter certification will expire 08/16/2025.

Emergency disaster drills are conducted and are appropriately documented. Last disaster drill was conducted on December, 2024. LPA observed licensing documentation to be properly posted, made available for review. Facility maintains a childcare roster that was also made available for review. Per licensee, there are no weapons or firearms in the home.

(Continue Report on Page 3...)

SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Melissa Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025

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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: KOZACZUK, PETER	FACILITY NUMBER: 414002986
	VISIT DATE: 02/28/2025

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 3...)
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 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.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage athttps://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/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.

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/.

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

During the exit interview, the licensee, Peter Kozaczuk, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed a Megan’s Law search on 02/28/2025.

No deficiencies were issued during today's visit. A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee, Peter Kozaczuk.

SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Melissa Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025

LIC809 (FAS) - (06/04)

Page: 3 of 3