214005422-6-13-2019-05-CC-LGOZ-BD4NZJ-20190613105425

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 214005422
Report Date: 06/13/2019
Date Signed: 06/13/2019 10:54:42 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:	VASQUEZ, DAMARIS E.		FACILITY NUMBER:	214005422
ADMINISTRATOR:	VASQUEZ, DAMARIS E.		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(415) 464-7473
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94901
CAPACITY:	14	CENSUS: 10	DATE:	06/13/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Licensee, Damaris E. Vasquez		TIME COMPLETED:	11:10 AM

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), Luis J. Gomez met with Licensee, Damarias E. Vasquez. Purpose of the inspection was explained and was for an Annual/Random inspection. Present in the facility is Licensee and helper (sister) caring for 10 children. (1 Infants 7 PreK 2 School age). Licensee is within capacity limits of the License. Licensee’s home is a 2 bedroom, 1 bathroom, 1-level house. Hours of Operation are: Mon- Fri 8:00-10:00pm. Daycare areas are: Living Room, Front Yard Area, Dining Room and Bedroom #1. Off Limit areas are: Kitchen, Bedroom #2 and Backyard. All off limit areas are properly barricaded with wooden and mesh fencing. LPA observed the following: Daycare area is clean, orderly with age appropriate toys, Legos and blocks for the children. Home has ample lighting and ventilation. Home has a working telephone, a working smoke and carbon monoxide detector, and 2 fully charged fire extinguishers. LPA observed cleaning supplies accessible to children, in the bathroom under the sink. Licensee states there are no guns or weapons in the home. Licensee’s cardiopulmonary resuscitation certifications expires: 7/2019. Licensee provides daily snacks and meals for children in care. All required postings are properly posted next to the main door. Licensee stated she has a pet dog in the home. Licensee stated the pet has all vaccinations. LPA reviewed the personnel files and children’s files and during today’s visit. LPA observed the children’s files are complete and up to date. LPA observed personnel files are missing helper’s proof of immunization. Continue to page 2. . .

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8832
LICENSING EVALUATOR NAME: Luis Gomez	TELEPHONE: (650) 393-9134
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2019

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 3

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: VASQUEZ, DAMARIS E.	FACILITY NUMBER: 214005422
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/13/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/14/2019 Section Cited CCR 102417(G)(4)	1 2 3 4 5 6 7	102417(G)(4) Operation of a Family Child Care Home. The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not be limited to: Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.	1 2 3 4 5 6 7	Licensee move cleaning supplies to off limit area by the due date: 6/14/2019. Licensee will submit proof of correction to licensing.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by; LPA observed cleaning supplies accessible to children, in the bathroom under the sink. This presents a potential health and safety risk to children in care.	8 9 10 11 12 13 14
Type B 06/27/2019 Section Cited HSC 1597.622	1 2 3 4 5 6 7	1597.622. Employee or Volunteer. The family child care home shall maintain documentation of the required immunization or exemption from immunization, as set forth in this section, in the personnel records that is maintained by the family child care home.	1 2 3 4 5 6 7	Licensee will obtain proof of helpers immunization and place them in the personnel file by the due date: 6/27/2019. Licensee will submit proof of correction to licensing.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by; LPA observed personnel files are missing helper’s proof of immunization. This is a potential health and safety risk to children in care.	8 9 10 11 12 13 14

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 Malig	TELEPHONE: (650) 266-8832
LICENSING EVALUATOR NAME: Luis Gomez	TELEPHONE: (650) 393-9134
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2019

LIC809 (FAS) - (06/04)

Page: 3 of 3

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: VASQUEZ, DAMARIS E.	FACILITY NUMBER: 214005422
	VISIT DATE: 06/13/2019

NARRATIVE

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Page 2. . .
During inspection,
*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 Malig	TELEPHONE: (650) 266-8832
LICENSING EVALUATOR NAME: Luis Gomez	TELEPHONE: (650) 393-9134
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2019

LIC809 (FAS) - (06/04)

Page: 2 of 3