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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214200004
Report Date: 06/27/2019
Date Signed: 06/27/2019 10:45:26 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:ANDRADE-WOLF, ANAFACILITY NUMBER:
214200004
ADMINISTRATOR:ANDRADE-WOLF, ANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 299-0862
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:14CENSUS: 11DATE:
06/27/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Licensee, Ana Andrade- WolfTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA), Luis J. Gomez met with Licensee, Ana Andrede- Wolf. Purpose of the inspection was explained and was for an Annual/Random inspection. Present in the facility is Licensee and 2 helpers caring for 11 children. (2 Infants 9 PreK). All Adults living in the home have Criminal Record Clearance on file. Licensee is within capacity limits of the License. Licensee’s home is a 3-bedroom, 2- bathroom, 1-level house. Hours of Operation are: Mon- Fri 7:30am- 5:30pm. Daycare areas are: Backyard, Playroom, Living Room, Bedroom #1 and Bathroom #1 Off Limit areas are: Office, Bedroom #2, Bathroom #2 and Garage. All off limit areas are properly barricaded with a child safe gates. There are no bodies of water in the Daycare area. LPA observed the following: Daycare area is clean, orderly, and equipped with wooden toys, puzzles and equipment for the children. Home has ample lighting and ventilation. Home has a cell telephone, a working smoke and carbon monoxide detector combo, and 2 fully charged fire extinguisher. LPA observed fireplace in the Living Room is properly barricaded. LPA inspected backyard for health and safety hazards. LPA observed all toys in the backyard are in good working condition. 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’s cardiopulmonary resuscitation certifications expires: 6/2020. Licensee conducted last emergency drill on 05/18/2019 and is properly logged. Licensee stated she provides all daily snacks and meals for children in care.

All required postings are properly posted in the daycare. Licensee stated she does not have pets in the home. LPA reviewed Personnel files, Children’s files and Facility Roster during today’s visit. LPA observed Personnel Files, Children’s and Facility Roster complete and up to date.

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

DATE: 06/27/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2019
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 2
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: ANDRADE-WOLF, ANA
FACILITY NUMBER: 214200004
VISIT DATE: 06/27/2019
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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.

>No deficiencies were 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: 06/27/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2019
LIC809 (FAS) - (06/04)
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