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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214200011
Report Date: 09/19/2019
Date Signed: 09/19/2019 04:45:54 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:AYALA, ELVIA GFACILITY NUMBER:
214200011
ADMINISTRATOR:AYALA, ELVIA GFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 892-5819
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY:14CENSUS: 5DATE:
09/19/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
03:55 PM
MET WITH:Elvia AyalaTIME COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA) Farhan Bashir-Tariq arrived at the facility above unannounced to conduct an Annual Inspection on this day and met with the Licensee Elvia Ayala. Purpose of the inspection was explained. Present there were 5 children in care with Licensee. Licensee was operating in compliance to the required licensed capacity and ratio limits as of today. LPA verified the background check clearance of the adults working or living in the home.

LPA and Licensee inspected the entire day care area for Health and Safety hazards. LPA observed that off limit areas were properly barricaded and made inaccessible to the children in care. There were multiple smoke detectors in the home. LPA tested the detectors. A Fire Extinguisher of size 2A10BC or bigger was also available in the home. First Aid kit is fully stocked and accessible. Per Licensee, there are no firearms or weapons in the home. Licensee states, there are no bodies of water and no pets in the home.

LPA observed that the house is in good repair and free of hazards with proper temperature and ventilation. Bathroom used for the day care has locks on the cabinet, where chemicals or detergents are stored. LPA observed that there is a variety of age appropriate toys, books and other learning material available in the home for the children in care. Per Licensee, Discipline policy is redirection or communication.

Licensee has current CPR and First Aid card valid until 12/2020. LPA also reviewed facility fire drill log. Per Log, last drill was conducted on July 18, 2019. Licensee is aware of the requirement of conducting and logging fire drills once every six months.

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SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8867
LICENSING EVALUATOR NAME: Farhan Bashir-TariqTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2019
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: AYALA, ELVIA G
FACILITY NUMBER: 214200011
VISIT DATE: 09/19/2019
NARRATIVE
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LPA reviewed facility records including all present children's files. LPA observed that files have records of immunization, names, addresses and telephone numbers of each child's authorized representatives. LPA reminded Licensee that All adults, 18 years and older living in the home, helper, or assistant must have finger print clearance and must be associated to the facility by submitting an LIC 9182 with a copy of CDL or CA. ID prior to having any contact with children in care, failure to do so could result in an immediate civil penalty.


LPA reminded Licensee that as of September 1, 2016, a person may not be employed or volunteer at a child care facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662.

LPA reminded Licensee that As of January 1, 2018, all staff is required to complete Mandated Child Abuse Reporter Training (AB1207) every two years. The training can be obtained online at www.mandatedreporterca.com. LPA encouraged the Licensee to frequently visit our website at www.ccld.ca.gov for licensing regulations and new updates. Facility can also email at childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list for the updates.

> Type B deficiencies were 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) 266-8867
LICENSING EVALUATOR NAME: Farhan Bashir-TariqTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2019
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: AYALA, ELVIA G
FACILITY NUMBER: 214200011
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/03/2019
Section Cited

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1597.622…Employee and Volunteer Immunization
(a) (1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

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This requirement is not met as Licensee was unable to present the immunization records for reviewing to LPA.

This poses a potential health and safety risk to the children in care.
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Type B
10/03/2019
Section Cited

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1596.954…Carbon monoxide detectors required; inspection
Every licensed child day care center shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

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This requirement is not met as evidenced, carbon monoxide detector was not in working condition. LPA performed the test, but detector did not respond to the test.
This poses potential health 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) 266-8867
LICENSING EVALUATOR NAME: Farhan Bashir-TariqTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2019
LIC809 (FAS) - (06/04)
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