073404524-1-28-2025-02-CC-MCAO-DDCSLT-20250128125853

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 073404524
Report Date: 01/28/2025
Date Signed: 01/28/2025 12:59:17 PM

Document Has Been Signed on 01/28/2025 12:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME:	CUSTODIO-NOMELLINI, CARMEN		FACILITY NUMBER:	073404524
ADMINISTRATOR/ DIRECTOR:	CUSTODIO-NOMELLINI, CARMEN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(925) 934-8396
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94598
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 4	CENSUS: 4	DATE:	01/28/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:53 AM
MET WITH:	Custodio-Nomellini, Carmen		TIME VISIT/ INSPECTION COMPLETED:	01:15 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	On 01/28/25 at 10:53 am Licensing Program Analysts (LPA) Mario Caro conducted an Unannounced Annual Inspection/Case Management at Carmen Custodio-Nomellini's Family Day Care Home. LPA met with Licensee, and explained the purpose of today’s inspection. LPA was granted permission to enter the facility. Days and hours of operation are Monday - Friday from 7:30 am - 5:30 pm. Present in the home were Licensee, 3 preschoolers, and 1 infant in care. LPA toured all ON-LIMIT areas of the home. LPA observed sufficient materials, toys, and play equipment for the day care children in the home. Furniture and equipment, such as cribs, mats, feeding chairs, and tables were age appropriate and in good condition. There were no baby walkers, exersaucers, jumpers or bouncers observed on the premises during today’s inspection. The home is sanitary, orderly, and safe for the day care children. The home is equipped with central heating and ventilation. There are no stairs inside the home. The Licensee has a working telephone in the home. LPAs observed a fully charged 3A-40-BC fire extinguisher and working smoke/carbon monoxide detectors. The Licensee states that she does not have any weapons or pets in the home. The Licensee states that she does not transport children. Licensee's mandated reporter expires 05-04-25 and cpr expired 02-24. This imposes a potential risk to the health, safety, or personal rights of clients. A Type B deficiency will be cited see deficiency page 809D. Licensee received a technical violation for not maintaining a proper sleep log. Licensee's day care is in one big room with cribs and cots. Licensee stated she is with the children as they sleep but wasn't aware she needed to document the 15 minute checks. documenting the time the infants lay down and wake up, but not documenting the 15 minute checks in-between. Licensee received a second Technical Violation for not having her parents rights certificate posted. Licensee has parents rights signed by each parent and was informed by LPA the certificate must remain posted. page 1

Mayla Mendoza	TELEPHONE: (510) 292-9724
Mario Caro	TELEPHONE: (510) 414-8926
	DATE: 01/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025

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 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: CUSTODIO-NOMELLINI, CARMEN	FACILITY NUMBER: 073404524
	VISIT DATE: 01/28/2025

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
26
27
28
29
30
31
32

IN USE AREAS: Classroom (converted garage), half bathroom, Bedroom far end of the hallway next to the kitchen. Hallway from classroom to bedroom , Side yard and Backyard
OFF LIMIT AREAS: Kitchen, Living room, Dining area, 2 bedrooms, Office, 2 bathroom inside home, laundry closet, and storage shed.
Isolation area : chairs in classroom near entrance

LPA reviewed Licensee's file, 4 children's files, and obtained a current roster.

Supervision of children was discussed with the Licensee and he understands that he must be present in the home during 80% of the operating hours of the day care and ensure that the children are supervised at all times.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

Licensee was reminded that all adults 18 and over living or working in the home, 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.

page 2

SUPERVISOR'S NAME: Mayla Mendoza	TELEPHONE: (510) 292-9724
LICENSING EVALUATOR NAME: Mario Caro	TELEPHONE: (510) 414-8926
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025

LIC809 (FAS) - (06/04)

Page: 3 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: CUSTODIO-NOMELLINI, CARMEN	FACILITY NUMBER: 073404524
	VISIT DATE: 01/28/2025

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
26
27
28
29
30
31
32

LPAs discussed the safe sleep regulations with licensee 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 licensee 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.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

On 01/28/25 , the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

In the areas that were evaluated, 1 regulatory type B violations were cited for the following violations: Licensee's CPR expired in 02-2024 Citation is issued on 809-D pages of this report.

page 3

SUPERVISOR'S NAME: Mayla Mendoza	TELEPHONE: (510) 292-9724
LICENSING EVALUATOR NAME: Mario Caro	TELEPHONE: (510) 414-8926
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 01/28/2025 12:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: CUSTODIO-NOMELLINI, CARMEN	FACILITY NUMBER: 073404524
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

102416(c)

Personnel Requirements

(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in that her CPR was expired 02-2024 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/11/2025
	Plan of Correction
1 2 3 4	Licensee will enroll in the CPR class and send LPA Caro proof of enrollment by POC Date 02-11-25.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Mayla Mendoza	TELEPHONE: (510) 292-9724
Mario Caro	TELEPHONE: (510) 414-8926
	DATE: 01/28/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025

LIC809 (FAS) - (06/04)

Page: 2 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: CUSTODIO-NOMELLINI, CARMEN	FACILITY NUMBER: 073404524
	VISIT DATE: 01/28/2025

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
26
27
28
29
30
31
32

The purpose of the inspection was to add a previous off limit bedroom to her on limit areas, LPA inspected the bedroom and allowed it to be used as of today's date. While at the home LPA did a walk through of the home and conducted the annuel inspection as well.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS. Exit interview conducted and report was reviewed with the licensee Carmen Custodio-Nomellini.

SUPERVISOR'S NAME: Mayla Mendoza	TELEPHONE: (510) 292-9724
LICENSING EVALUATOR NAME: Mario Caro	TELEPHONE: (510) 414-8926
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025

LIC809 (FAS) - (06/04)

Page: 5 of 5