214005157-11-25-2019-05-CC-FBTQ-BJ9VNW-20191125153549

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 214005157
Report Date: 11/25/2019
Date Signed: 11/25/2019 03:36:05 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:	RIBEIRO, KARINA M.		FACILITY NUMBER:	214005157
ADMINISTRATOR:	RIBEIRO, KARINA M		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(415) 246-1409
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	14	CENSUS: 12	DATE:	11/25/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Mayara Correiadonascim		TIME COMPLETED:	03:50 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	Licensing Program Analyst (LPA) Farhan Bashir-Tariq met with Licensee's Helpers, Mayara Correiadonascim (S1) and Elma Vasquez (S2) for an Annual Random Inspection on 11/25/19. The purpose of the inspection was explained. Licensee was not present at the time of inspection. Per S1, Licensee was out for an appointment. Present, there were 12 children in care with two helpers. Licensee lives with husband. All adults living or working in the home have fingerprints clearance on file. Licensee is operating within the capacity and ratio limits as of today 11/25/19.The hours of operation are M-F, 7:30 AM-5:30 PM. Licensee provides Breakfast, Lunch and 2 snacks. LPA and S1 inspected the entire day care area for Health and Safety Hazards. This is a three bedroom and two-bathroom single family home. Day care areas: Play room, Sleep area, Backyard, Bathroom #1. Bedroom #1 and Bedroom #2 are used for napping only. Off limit areas: Kitchen, Bedroom #3, Master bathroom, and Living area. All off limit areas are properly barricaded and made inaccessible to the children in care. LPA observed, there is a pool in the back yard. Pool has been blocked off with a tall fence. Gate at the entrance of pool has been blocked off and kept locked at all times. S1 states, there are no weapons or firearms in the home. S1 states, there are no pets in the home. The house is in good repair and free of hazards with proper temperature and ventilation. There is a carbon monoxide detector, a smoke detector, a fully charged fire extinguisher and a working telephone available in the home. There is a First Aid kit available in the home. There is a variety of age appropriate toys in the home. Licensee,S1 and S2 all have CPR and First Aid cards, which are valid until 5/2021,7/2020 and 5/2021 respectively. LPA reminded S1 to conduct the fire or emergency drills at least once every six months and drills must be logged. Licensee has a log for each drill being conducted. Per licensee’s log, last drill was conducted on May 3, 2019. S1 presented a current roster of children. LPA collected a copy of the roster. Children's files and adult files were reviewed. Children's files are current and complete. LPA reviewed the identification and emergency information form for every child for proper names and numbers filled. Adult files are complete with immunization records and first aid and CPR certification. Continuation on next page...

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Farhan Bashir-Tariq	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 11/25/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2019

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: RIBEIRO, KARINA M.	FACILITY NUMBER: 214005157
	VISIT DATE: 11/25/2019

NARRATIVE

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LPA reminded facility that All adults, 18 years and older living in the home, helper, or assistant must have finger print clearance and must be associated to the facility by submitting an LIC 9182 with a copy of CDL or CA. ID prior to having any contact with children in care failure to do so could result in an immediate civil penalty.

Currently, none of the children present today are required regular medication (IMS). For Incidental Medical Services (IMS) information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan of 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 Facilities and ADA, available at: http://www/ada/gov/childqanda.htm

LPA reminded facility , As of January 1, 2018, all staff is required to complete Mandated Child Abuse Reporter Training (AB1207) every two years. The training can be obtained online at www.mandatedreporterca.com. LPA observed the training completion certificates for Licensee and staff. LPA encouraged facility to frequently visit our website at www.ccld.ca.gov for licensing regulations and new updates. Facility can also email at childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list for the updates. Safe Sleep Regulation, Safe Sleep Environment, Items not permitted in a home and SIDS handouts were provided to S1.

>No deficiencies were cited today under Title 22 Division 12 of the California Code of Regulations.

This report and rights to comment and appeal were discussed with S1. This report must be available in the facility for public review. Notice of site visit shall be posted for 30 days from today's visit. Facility was advised for any additional questions to call Office, M-F, 8AM-5PM at 650-266-8800 . For Rules and Regulations, visit the Website: www.cdss.ca.gov

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Farhan Bashir-Tariq	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 11/25/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2019

LIC809 (FAS) - (06/04)

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