Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384002043
Report Date: 03/10/2016
Date Signed 03/10/2016 11:19:41 AM

COMPREHENSIVE INSPECTION
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: 11DATE:
03/10/2016
TYPE OF VISIT:Annual/RequiredUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Julie FellomTIME COMPLETED:
11:25 AM
NARRATIVE
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LPA Huang and Avila met with Licensee Julie Fellom for an Annual Required visit at this facility today. Purpose of the visit was explained to her. Present at the day care today were also 2 staffs with 11 children in care. The home was toured and inspected for health and safety hazards. This is a duplex, 59 & 61 Grand view St. Julie is living in 59 Grand view which has 3 floors 3 bedrooms. Licensee's partner owns this building. Current residents of the home are Licensee and her partner. Holly moved out last month. Day care areas are: the play room, a small kitchen area, bathroom and the backyard on the lower level; the playroom is on the street level. The lowest level has direct access to the back yard for outdoor activity. Off limits area are: the entire top level, the storage, old kitchen, and the garage on the street level. At least one working smoke detector and one working telephone were tested. A 2A10BC fire extinguisher is fully charged. First aid supplies are available for children. Per licensee, there is no firearms or weapons in the home. Facility has Chickens in the backyard. Facility conducts fire drills at lease once every quarter and was properly logged. There are plenty of variety of children's toys, tables, chairs and equipment that are available for children in the day care area and all appeared to be safe and age appropriate for children. Licensee is utilizing the children's roster and it is updated. One of the staff took off the Parents rights poster and the disaster plan to laminate them. Licensee state will make sure put them back on the wall. License was posted. Licensee has current pediatric CPR and First Aid training last Saturday and the card has not arrive yet. LPA will check when come back. All Helpers also have current CPR and First Aid training. Facility provides snacks and lunch, parents bought food for children. Disciplinary policy was discussed with licensee today. Facility records were reviewed. Facility has purchased liability insurance for the day care. LPAs informed Licensee that starting September 2016, all staffs must have flu, measles and whooping cough shoots.

Please see deficiencies cited today under CCR, Title 22, Division 12, Chapter 3:
This report and rights to comment were discussed with licensee. This report must be available in the facility for public review. LPAs observed Licensee posted the Notice of site visit.
SUPERVISOR'S NAME: Suzanne Roman-ClarkTELEPHONE: (650) 266-8843
LICENSING EVALUATOR NAME: Karen HuangTELEPHONE: (650) 266-8843
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2016
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: FELLOM, JULIE ANNA
FACILITY NUMBER: 384002043
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2016
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/17/2016
Section Cited
H&S1596.8595
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Health and Safety Code Sections 1596.8595 and 1596.8895

LPAs observed all children do not have LIC9224, Acknowledgement of Receipt of Licensing Reports in file for the non-compliance meeting in 3/13/15 and the type A cited in 7/9/15.
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Licensee will ensure to provide all parents with these documents and signed LIC9224s by the due date, 3/17/16.
Type B
03/17/2016
Section Cited
102418(g)
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Immunization. Licensee shall document and maintain each child’s immunizations as long as the child is enrolled.
LPAs observed that child #7 and #10 do not have immunization in file
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Licensee will ensure all children's files are completed by the due date, 3/17/16.
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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) 266-8843
LICENSING EVALUATOR NAME: Karen HuangTELEPHONE: (650) 266-8843
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2016
LIC809 (FAS) - (06/04)
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