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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214005289
Report Date: 05/08/2019
Date Signed: 05/08/2019 11:22:53 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:BLUNCK-RIBEIRO, ISABELLAFACILITY NUMBER:
214005289
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 6DATE:
05/08/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Isabella Blunck- RibeiroTIME COMPLETED:
11:35 PM
NARRATIVE
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Licensing Program Analyst (LPA), Luis J. Gomez met with Licensee, Isabella Blunck- Ribeiro. Purpose of the inspection was explained and was for an Annual/Random inspection. Present in the facility is Licensee and helper caring for 6 children ( 4 infants and 2 PreK). LPA observed licensee is over capacity with 4 infants and 2 prek children in care. Licensee rents home, which is a 3 bedroom, 2 bathroom, 2- level house. Hours of Operation are: Mon-Fri 7:30- 5:30pm. Daycare areas are: Living Room, Bedroom #2 and Lower Yard Area. Off Limit areas are: Kitchen, Bedroom #1, Entire Upstairs, (Bedroom #3 and Bathroom #2) and Deck Area ( Pass through only). All off limit areas are properly barricaded. LPA observed the following: Daycare area is orderly, and equipped with age appropriate toys and equipment for the children. Home has ample lighting and ventilation. Home has a working cell phone, a working smoke detector, 2 carbon monoxide detectors, and a fully charged fire extinguisher. LPA observed licensee does not have current CPR/ 1st aide certification. Chimney is properly barricaded and inaccessible to children in care. Licensee has a pet dog in the home. Pets vaccinations are current. There are no bodies of water in the Home. There are no poisons, detergents, cleaning products, or sharp objects accessible to daycare children. Licensee states there are no guns or weapons in the home. Licensee provides daily snacks and meals for children in care. LPA reminded licensee of her annual payment that is past due. LPA reviewed children's files during today's visit. LPA observed licensee is missing required immunization records for all children in care.

LPA observed licensee does not have a current children's roster.

LPA observed helper in daycare without required fingerprint clearance.

See Page 2. . .
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8832
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 393-9134
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2019
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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: BLUNCK-RIBEIRO, ISABELLA
FACILITY NUMBER: 214005289
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/12/2019
Section Cited
CCR
102416(c)
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102416(c) Personnel Requirments. The licensee and other personnel as specified shall complete training on preventive health practices including pediatric cardiopulmonary resuscitation and pediatric first aide, pursuant to Health and Safety Code Section 1596.866.
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Licensee will enroll and complete a CPR/ 1st aide training course before the due date: 6/12/2019. Licensee will submit proof of certification to licensing.
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The requirement is not met as evidenced by LPA observed licensee does not have current CPR/ 1st aide certification. This presents a potential health and safety risk to children in care.
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Type B
05/15/2019
Section Cited
CCR
102418(g)
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102418(g) Immunization. Licensee shall document and maintain each child's immunization as long as the child is enrolled.
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Licensee will have a copy of each child's immunization records on file at the facility by the due date: 5/15/2019.
Licensee will submit proof of children's immunization records to licensing.
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The requirement is not met as evidenced by LPA observed missing children's immunization records for all children in care. This presents a potential health and safety risk to children in care.
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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: Alma MaligTELEPHONE: (650) 266-8832
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 393-9134
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2019
LIC809 (FAS) - (06/04)
Page: 5 of 5
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: BLUNCK-RIBEIRO, ISABELLA
FACILITY NUMBER: 214005289
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/09/2019
Section Cited
CCR
102370(d)(1)
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102370(d)(1) Criminal Record Clearance. All individuals are subject to criminal record review as specified in section 1596.871 prior to working, residing or volunteering in a licensed home, shall obtain a California clearance or criminal record exemption as required by the department.
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Licensee will have helper fingerprinted before the due date: 5/9/2019.

Civil penalties were issued today in the amount of $100.00.
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The requirement is not met as evidenced by LPA observed helper in daycare without required fingerprint clearance. This presents an immediate health and safety risk to children in care.
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Type A
05/09/2019
Section Cited
CCR
102416.5(a)
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102416.5(a) Staffing Ratio and Capacity. The capacity as specified on the license shall be the maximum number of children for whom care can be provided.
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Licensee stated she will reduce her capacity by the due date: 5/9/2019
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The requirement is not met as evidenced by LPA observed facility is over capacity with 4 infants and 2 prek children in care. This presents an immediate health and safety risk to children in care.
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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: Alma MaligTELEPHONE: (650) 266-8832
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 393-9134
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2019
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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: BLUNCK-RIBEIRO, ISABELLA
FACILITY NUMBER: 214005289
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/15/2019
Section Cited
CCR
102417(g)(8)
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102417(g)(8) Operation of a Family Child Care Home. All homes shall have a current roster of the children.
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Licensee will need an updated and current children's roster before the due date: 5/15/2019.

Licensee will need to provide proof of current roster to licensing.
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This requirement is not met as evidenced by LPA observed missing required childrens roster. This presents a potential health and safety risk for children in care.
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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: Alma MaligTELEPHONE: (650) 266-8832
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 393-9134
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2019
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: BLUNCK-RIBEIRO, ISABELLA
FACILITY NUMBER: 214005289
VISIT DATE: 05/08/2019
NARRATIVE
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Page 2. . .
During inspection, LPA discussed:
*Required children's records, staff records and capacity requirements for small license
*Incidental Medical Services (IMS) policy was discussed.
*Licensee was reminded about having all Staff and Volunteers provide proof of immunization against influenza, pertussis, and measles or qualifies for an exemption.
*Licensee was reminded about the Provider Information Notices (PINs) on CCLD website.
*Licensee was reminded about Mandated Reporter Training available on CCLD website (www.ccld.ca.gov or www.mandatedreporterca.com)
*Licensee was given information regarding ‘Safe Sleep’ practices.

>See attached deficiencies page for deficiencies issued today under Title 22 Division 12 of the Ca. Code of Regulations.


>This report and rights to comment and appeal were discussed with Licensee. This report must be available in the facility for public review. Notice of site visit was observed being posted.
Licensee was advised any additional questions to call Office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website: www.cdss.ca.gov
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8832
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 393-9134
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2019
LIC809 (FAS) - (06/04)
Page: 2 of 5