Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384002043
Report Date: 07/09/2015 12:00:00 AM
Date Signed 07/09/2015 12:52:50 PM

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:FELLOM, JULIE ANNAFACILITY NUMBER:
384002043
ADMINISTRATOR:FELLOM, JULIE ANNAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 971-4963
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94114
CAPACITY:14CENSUS: 13DATE:
07/09/2015
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Cherysse CalhounTIME COMPLETED:
01:00 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
LPA Huang met with Teacher Cherysse Calhoun for a Case Management visit today at this facility. Purpose of the visit was explained to Cherysse. Licensee was not at the facility during the visit today. Present at the facility were total of 4 staffs with 13 children in care, one of the child was enrolled in Kindergarten for the fall semester. LPA talked to the three other staffs who do not have criminal record clearance, they were all working for the summer time only and get pay for the work. All of them stated that they never have fingerprint done before. This visit was to follow up for the non-compliance meeting in March 13, 2015. In the meeting, Licensee stated that on the Wednesday hiking, they have about 17 children. It is over the Licensed capacity.


Facility was cited today under Title 22, Div.12 and Chapter 3.


This report and right to appeal were explained to the Licensee. Notice of site visit was posted. A copy of LIC9224 was provided to Licensee during the visit today to inform parents about the type A deficiencies cited today.
SUPERVISOR'S NAME: Suzanne Roman-ClarkTELEPHONE: (650) 266-8823
LICENSING EVALUATOR NAME: Karen HuangTELEPHONE: (650) 266-8843
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2015
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 2


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: FELLOM, JULIE ANNA
FACILITY NUMBER: 384002043
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/09/2015
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/13/2015
Section Cited
102370(d)(1)
1
2
3
4
5
6
7
Criminal Record Clearance. All individuals subject to a criminal record review as specified in Section 1596.871 prior to working, residing or volunteering in a licensed home, shall obtain a California clearance or a criminal record exemption as required by the Department.
1
2
3
4
5
6
7
Licensee will ensure all staff over 18 must have criminal record clearance. Civil penalty of $500 was assessed for this violation. Licensee will ensure all staff must have criminal record clearance before started working by the due date, 7/13/15.
8
9
10
11
12
13
14
LPA observed that there was one staff who is over 18 has no criminal record clearance.
8
9
10
11
12
13
14
Type A
07/16/2015
Section Cited
1
1
2
3
4
5
6
7
102416.5(a) Staffing Ratio and Capacity. The capacity specified on the license shall be the maximum number of children for whom care can be provided.
Licensee stated in the non-compliance meeting that they have above 17 children on hiking days.
1
2
3
4
5
6
7
Licensee will ensure that they meets the Licensed capacity when they are on all hiking days. Licensee will provide a plan of correction to LPA Huang by the due date, 7/16/15.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Suzanne Roman-ClarkTELEPHONE: (650) 266-8823
LICENSING EVALUATOR NAME: Karen HuangTELEPHONE: (650) 266-8843
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2015
LIC809 (FAS) - (06/04)
Page: 2 of 2