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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214005476
Report Date: 03/12/2020
Date Signed: 03/12/2020 12:00:21 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:LIMA, BRUNA R.FACILITY NUMBER:
214005476
ADMINISTRATOR:LIMA, BRUNA R.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 747-1921
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:12CENSUS: 6DATE:
03/12/2020
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Bruna LimaTIME COMPLETED:
12:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Farhan Bashir-Tariq met with the Licensee, Bruna Lima for a case management Inspection today. Purpose of the inspection was explained. Present, there were 6 (2 infants& 4 Preschoolers) children in care with one Helper. Licensee is operating within the capacity and ratio limits as of today 3/12/20.

LPA observed an uncleared adult (S1) working in the home on a previous visit on 3/5/20. Licensee failed to provide the relevant documents regarding the fingerprints clearance with correct dates . S1's association with licensee began on 3/6/20.


> Type A deficiency was cited today under Title 22 Division 12 of the California Code of Regulations: See LIC 809D.

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 shall be posted for 30 days from today's visit. Licensee 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 LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Farhan Bashir-TariqTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2020
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: LIMA, BRUNA R.
FACILITY NUMBER: 214005476
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/13/2020
Section Cited

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102370…Criminal Record Clearance. (d)All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or (2) Request a transfer of a criminal record clearance as specified in Section 102370(j)
This requirement is not met as evidenced by records review:
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 Based on records review and observation, S1 was working in the home on 3/5/20 without the background check clearance.
This poses an immediate heath and safety risk to the 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: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Farhan Bashir-TariqTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2020
LIC809 (FAS) - (06/04)
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