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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004529
Report Date: 06/29/2021
Date Signed: 06/30/2021 01:39:49 PM

Document Has Been Signed on 06/30/2021 01:39 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:BURRELL, AMINA M.FACILITY NUMBER:
414004529
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 7DATE:
06/29/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Amina BurrellTIME COMPLETED:
02:00 PM
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Licensing Program Analyst's (LPAs) Tapia-Mandujano and Yee arrived at facility and met with licensee Amina Burrell, to do a Plan of Correction for deficiencies cited on 6/24/21 (Refer to LIC 9099D pages for more details). Purpose of the visit was explained. Present in the home are licensee, licensee's husband, and a total of seven children (one infant and six preschool).

Licensee's husband has registered for a CPR and First Aid class on August 14th. Licensee is registered for July 19,20, 21,24 (2 hours each day, total 8 hours).

LPAs explained and provided a copy of Tittle 22 regulations for capacity of a Small and Large Family Child Care Home. Capacity worksheet was also provided.

Licensee has submitted a Large License application. Fire clearance has been granted. Licensee was advised that once approved for a Large License, two fully qualified adults will need to be present while caring for up to 14 children.

LPAs has cleared deficiencies for over capacity and CPR & First Aid for husband on 6/29/21.

>A copy of this report was emailed to licensee. A signed copy of this report will be kept on file and made available 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: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2021
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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