214200085-6-11-2019-05-CC-LGOZ-BD2QKD-20190611121409

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 214200085
Report Date: 06/11/2019
Date Signed: 06/11/2019 12:14:20 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:	GONZALEZ ORTEGA, DEVORA		FACILITY NUMBER:	214200085
ADMINISTRATOR:	GONZALEZ ORTEGA, DEVORA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(415) 455-8138
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94901
CAPACITY:	14	CENSUS: 9	DATE:	06/11/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Licensee, Devora Gonzalez Ortega		TIME COMPLETED:	12:30 PM

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, Devora Gonzalez Ortega. Purpose of the inspection was explained and was for an Annual/Random inspection. Present in the facility is Licensee and helper caring for 9 children. (2 Infants 5 PreK 2 School age ). Licensee is within capacity limits of the License. LPA observed facility helper does not have her fingerprint clearance. Licensee’s home is a 2 bedroom, 2 bathroom, 1-level house. Hours of Operation are: Mon- Sat 7:00am- 6:00pm. Daycare areas are: Living Room, Bedroom #2, Bathroom #2, Kitchen, Backyard and Deck. Off Limit areas are: Bedroom #1, Bathroom #1 and Front Yard. All off limit areas are properly barricaded. LPA observed the following: Daycare area is equipped with age appropriate toys and equipment for the children. Home had individual cubbies for each child. Home has ample lighting and ventilation. Home has a telephone, a working smoke and carbon monoxide detector, and a fully charged fire extinguisher. 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: 7/2019. Licensee conducted last emergency drill on 2/13/2019. Licensee stated she provides daily snacks and meals for children in care. Licensee stated several children also come with their own food to the daycare. All required postings are properly posted next to the main door. Licensee stated there is a pet dog in the home. Licensee stated the pet has vaccinations. LPA reviewed the facility roster and children's files during today’s visit. LPA observed the facility roster and children’s files are complete and up to date. See Page 2. . .

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8832
LICENSING EVALUATOR NAME: Luis Gomez	TELEPHONE: (650) 393-9134
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2019

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: GONZALEZ ORTEGA, DEVORA	FACILITY NUMBER: 214200085
	VISIT DATE: 06/11/2019

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: 06/11/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2019

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: GONZALEZ ORTEGA, DEVORA	FACILITY NUMBER: 214200085
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/11/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/14/2019 Section Cited CCR 102370(d)(1)	1 2 3 4 5 6 7	102370(d)(1) Criminal Record Clearance. All individuals subject to criminal record review as specified in section 1596.871 prior to working residing or volunteering in a licensed home, shall obtain a California clearance or criminal record exemption as required by the department.	1 2 3 4 5 6 7	Licensee will have facility helper fingerprinted by the due date: 6/14/2019. Licensee will submit proof to licensing.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by LPA observed facility helper does not have her fingerprint clearance. This is an immediate health and safety risk to children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 06/11/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2019

LIC809 (FAS) - (06/04)

Page: 3 of 3