Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384002043
Report Date: 03/20/2017
Date Signed 03/20/2017 10:27:13 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: 8DATE:
03/20/2017
TYPE OF VISIT:Annual/RequiredUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Julie FellomTIME COMPLETED:
10:30 AM
NARRATIVE
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LPA Huang 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 1 staff, 1 parent with 8 children in care, facility does not accept infants. 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. 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. Facility has a working smoke detector, carbon monoxide detector and one working telephone. 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 two chickens in the backyard and two dogs stay upstairs. 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. Licensee and staff have current pediatric 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. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: http://www.ada.gov/childqanda.htm. Facility was also informed that as of September 1, 2016, a person may not be employed or volunteer at a child care facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662. Licensee and one of her staff have current required Immunization record in file.

Please see next page for deficiency cited today under Title 22, Div.12 and Chapter 3.
This report and rights to appeal were discussed with Licensee and must be made available to the public upon request. LPA observed Licensee posting report and the report shall remain posted for 30 days. For quarterly update on Licensing information, go to CCL website: www.ccld.ca.gov. For Provider Information Notice: ccld.ca.gov/PG5098.htm.
SUPERVISOR'S NAME: Suzanne Roman-ClarkTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Karen HuangTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2017
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: 03/20/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/17/2017
Section Cited
1596.7995
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Health and Safety code 1596.7995 and 1597.662
a person may not be employed or volunteer at a child care facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption.
LPA observed that one of the staff do not have proof of all required Immunization on file.
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Licensee will ensure all staff and herself have been immunized against influenza, pertussis, and measles or qualifies for an exemption by the due date, 04/17/17.
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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) 266-8800
LICENSING EVALUATOR NAME: Karen HuangTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2017
LIC809 (FAS) - (06/04)
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