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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004887
Report Date: 06/21/2022
Date Signed: 06/21/2022 11:29:08 AM

Document Has Been Signed on 06/21/2022 11:29 AM - 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:KERRIGAN, DANA ELIZABETHFACILITY NUMBER:
414004887
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
06/21/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:06 AM
MET WITH:Dana KerriganTIME COMPLETED:
11:22 AM
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On June 21, 2022, Licensing Program Analyst (LPA), Sheran Lo met with applicant, for a schedule prelicensing inspection at the facility. Inspection included a technical assistance review for COVID-19 prevention and mitigation measures. Present is the applicant and partner. Applicant owns the home, which is a two bedroom, one bathroom, ranch style home. Living in the home is applicant and partner. Criminal record clearances are on file. Days and hours of operation are Monday - Friday, 6:00 AM. to 4:00 PM. Childcare Area: Main Dining Room, Bathroom, Side Drive Way, Kitchen, and Living Room (Pass through only). Off-limit Area: Bedroom 1 & 2. LPA inspected home with applicant for health and safety hazards.

LPA observed the following: Childcare area was clean and orderly with a variety of age appropriate wooden toys, books and padded sitting area for the children. Furniture and playthings inspected are new and in good condition. Nap mats will be used in childcare area for rest time. Baskets had been added under the changing table for storage of children’s belongings. Infant changing table is located in the room. Playroom had one child size table and several chairs for meals and activities. Per applicant, children will be provided and served meals in the playroom. Accessible cabinets and drawers in the kitchen and bathroom had child safety locks installed. Bathroom was in operating condition with adequate supplies. Childcare area has 3 windows for ventilation and lighting which the opening is inaccessible to children. LPA observed all accessible electrical outlets, trash bins had been properly covered. Detergents and cleaning supplies were made inaccessible, stored under the kitchen sink. Facility has functioning cell phone, smoke/ carbon monoxide detector combo and fire extinguishers (2A:10:BC). Per applicant, there is one pet dog and vaccination is in file.

Per applicant, there are no guns or weapons in the home. Playroom was free of hazards or dangerous conditions. Isolation area for an ill child will be in the Living Room. Applicant was informed that the Department must be notified that prior to use of any off-limits areas. Licensing forms and posting requirements were reviewed with the applicant. LPA discussed licensing regulations and the capacity requirements. Any children under 10 years of age will be counted in the capacity.

SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Sheran Lo
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2022
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: KERRIGAN, DANA ELIZABETH
FACILITY NUMBER: 414004887
VISIT DATE: 06/21/2022
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Applicant understands that fire/earthquake drills are to be conducted every six months and recorded. Applicant understands that baby walkers, bouncers, and excersaucers are not allowed. Smoking is prohibited in family childcare homes. Applicant's CPR/1st Aid certification was current, expiring: 5/2024. Mandated Reporter Training was current, expiring: 12/2022.

Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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 if this regulation is violated.

LPA discussed the safe sleep regulations with applicant 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. LPA also informed [applicant, licensee, or facility representative] 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.

This facility plans to provide Incidental Medical Services – IMS. For IMS information , see PIN 22-02-CCP. 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: http://www.ada.gov/childqanda.htm

LPA reviewed with [applicant, licensee, or facility representative] the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted Entrance Checklist was provided to the applicant.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Sheran Lo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
LIC809 (FAS) - (06/04)
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