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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214005507
Report Date: 09/15/2021
Date Signed: 09/15/2021 02:01:26 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:CANALES, EVELYN A.FACILITY NUMBER:
214005507
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 3DATE:
09/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Licensee, Evelyn A. CanalesTIME COMPLETED:
12:30 PM
NARRATIVE
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On 9/15/2021 at 10:20A.M. Licensing Program Analyst (LPA), Luis J. Gomez met with Licensee, Evelyn Canales. Purpose of the inspection was explained and is for an unannounced Annual/Random inspection. During inspection, LPA reviewed COVID-19 best practices with the licensee. Present was the licensee caring for three children. All children present are preschool age. Licensee is within capacity limits of the license on this day. Licensee home is a three -bedroom, two -bathroom, two -level townhouse. Days and hours of operation are Monday – Friday, 8:00 A.M. to 5:00 P.M. Day-care Area: (Lower Level) Living Room (Playroom), Dining Room, Patio and Bathroom #1 Off-limit Area: (Upper Level)Bedroom #1, Bedroom #2, Bedroom #3 and Bathroom #2. LPA inspected home with licensee for health and safety hazards.

At 10:25A.M., LPA observed the following: Day-care was clean, orderly with a variety of age appropriate books and toys for the children. Furniture and playthings inspected were in good repair. Off-limit areas are properly barricaded. Children’s cubbies were located in entry way for storage. LPA observed child size tables and several chairs for activities. For nap time, LPA observed padded and cleanable mats stored in playroom. Bathroom #1 was clean with adequate supplies for the children.

At 10:30A.M., LPA observed accessible detergents, behind toilet in bathroom #1. Licensee moved detergents during inspection to off-limit area. Bathroom fixtures were in operating condition. Facility was the proper temperature with adequate ventilation and natural lighting. Outlets and trash bins had been covered. Home had a functioning cell phone, smoke / carbon monoxide detector and a fully charged fire extinguisher (2A:10BC), located in the kitchen. First aid kit located in bathroom #1.

At 10:40A.M., LPA inspected outdoor patio area. Patio area was completely enclosed with tall fencing. Patio had turf padding and plenty of shading. LPA did not observe any pools, fishponds, jacuzzi or bodies of water in the home. REFER TO 809-C FOR CONT.)

SUPERVISOR'S NAME: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021
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: CANALES, EVELYN A.
FACILITY NUMBER: 214005507
VISIT DATE: 09/15/2021
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At 11:10A.M. LPA reviewed the facility records.
At 11:20A.M., LPA observed children's files missing documents including: Consent for Medical Treatment (LIC627), Notification of Parent’s Rights (LIC995) and Affidavit for Liability Insurance (LIC 282). Licensee reminded licensee to conduct and document required emergency disaster drills every six months. Technical Assistance LIC 9102TA was issued during inspection. Children's Roster (LIC 9040) was updated during inspection. LPA reminded licensee to renew Mandated Reporter Training Certification. Licensee's CPR/ 1st aid certification is current, expiring: 1/16/23. All required forms were posted in the hallway including: License, Emergency Disaster Plan and the Parent's Rights. Licensee stated there are no guns or weapons in the home. Per Licensee, she provides transportation for day-care children. LPA inspected licensee's vehicle. Per licensee, she provides all daily snacks and meals. Licensee has a cat, mouse and birds. Per licensee pet cat is vaccinated.

Incidental Medical Services (IMS) was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding Americans with Disabilities Act (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 Centers and the ADA, available at: www.ada.gov/childqanda.htm.

During inspection,


·Licensee was informed about the Provider Information Notices (PINs) on CCLD website. Safe Sleep handout and was discussed with licensee.
·Licensee was reminded about Mandated Reporter training available on CCLD website. Training must be completed every 2 years. Training can be taken online at www.mandatedreporterca.com
·LPA discussed Covid-19 best practices including: In-take procedure, mask wearing, safety checks, social distancing and the disinfecting of high surfaces.

Based on today's inspection, deficiencies were observed in the areas evaluated according the Title 22 Division 12 Ca. Code of Regulations. Exit interview and the plan of correction was discussed with Licensee, Evelyn Canales, and her signature of this form acknowledges receipt of these documents.



>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 inspection was posted. Licensee was advised any additional questions to call Office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website: www.ccld.ca.gov
SUPERVISOR'S NAME: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021
LIC809 (FAS) - (06/04)
Page: 2 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: CANALES, EVELYN A.
FACILITY NUMBER: 214005507
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2021
Section Cited

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102417(g)(4) Operation of Family Child Care Home. 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. This requirement is not met as evidenced by:
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Based on observations, LPA confirmed licensee had accessible cleaning detergents located under the toilet in bathroom #1. This poses a potential health and safety risk to children in care.
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Type B
09/22/2021
Section Cited

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102417(g)(7) Operation of a Family Child Care Home. An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care. This requirement is not met as evidenced by:
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Based on File Review, LPA confirmed children's files missing required documentation including: Consent for Medical Treatment (LIC627), Notification of Parent’s Rights (LIC995) and Affidavit for Liability Insurance (LIC 282). This poses a potential health and safety risk to children in care.
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Proof of correction will be submitted to the LPA via email.
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: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3