Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384002281
Report Date: 04/14/2017
Date Signed 04/14/2017 10:24:38 AM

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:PUREVDORJ, TUULFACILITY NUMBER:
384002281
ADMINISTRATOR:PUREVDORJ, TUULFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 513-2159
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94118
CAPACITY:14CENSUS: 9DATE:
04/14/2017
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Tuul PurevdorjTIME COMPLETED:
10:30 AM
NARRATIVE
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2: LPA Huang met with Licensee Tuul Purevdorj for an Annual Random visit at this facility today. Purpose of the visit was explained to her. Present at the day care today were two other staff with 9 children in care, 3 of them were infants. The home was toured and inspected for health and safety hazards. Licensee rents the house. Licensee is the only person lives at this home. There is one bedroom, 1 1/2 bath, a play room, dining/Kitchen area and the backyard in this facility. The whole home is open for day care. Facility has a working smoke detector, a carbon monoxide detector and a working telephone. A 2A10BC fire extinguisher is fully charged. First aid supplies are available for children. Per Licensee, there is no pet, no firearms or weapons in the home. Facility conducts fire drills once every month and was properly logged There are children's toys, tables, chairs and equipment available for children in the day care area and all appeared to be safe and age appropriate. If there were ill child, Licensee would separate them in the couch by the entrance while waiting for parent to pick them up. Licensee is utilizing the children's roster and it is updated. Parents rights poster and the License are posted. Licensee has current pediatric CPR and First Aid training. Facility provides meal to children. Disciplinary policy was discussed with Licensee today. Facility records were reviewed. Facility has purchased liability insurance for her day care. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes 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 (every year), pertussis (every 10 years), and measles (only one time) or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662. All staff have current required Immunization record.

There is no deficiency cited against the facility under CCR,Title 22, Div. 12, Chapt. 1:
This report and rights to appeal were discussed with the 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: 04/14/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2017
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: PUREVDORJ, TUUL
FACILITY NUMBER: 384002281
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/15/2017
Section Cited
H&S 1597.622
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Employee and Volunteer Immunization: H&S 1597.622 (a) (1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Licensee and staff do not have proof the required staff immunization.
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Licensee will have all proof of immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662 by the due date, 5/15/17.
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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: 04/14/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2017
LIC809 (FAS) - (06/04)
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