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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214200202
Report Date: 11/08/2019
Date Signed: 11/08/2019 03:32:41 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:WAREN, SANDYFACILITY NUMBER:
214200202
ADMINISTRATOR:WAREN, SANDYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 479-5885
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:14CENSUS: 12DATE:
11/08/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Maria Lezama, Jacquelin AnguianoTIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Farhan Bashir-Tariq met with Licensee's assistants, Maria Lezama (S1) and Jacquelin Anguiano (S2) for an Annual Random Inspection on 11/08/19. The purpose of the inspection was explained. Present, there were 12 children in care with the helpers. Facility is operating within the capacity and ratio limits as of today 11/08/19. The hours of operation are M-F, 7:30 AM-5:30 PM. Licensee provides Breakfast, Lunch and 2 snacks.

LPA and Staff inspected the entire day care area for Health and Safety Hazards. All off limit areas are properly barricaded and made inaccessible to the children in care. S1 states that there is no pool, spa or any other body of water in the home. S1 states, there are no weapons or firearms in the home. There is a carbon monoxide detector, a smoke detector, a fully charged fire extinguisher and a working telephone available in the home. There is a First Aid kit available in the home. There is a variety of age appropriate toys in the home. There is a sufficient amount of sleeping matts available in the home. Both S1 and S2 have CPR and First Aid cards valid until 7/31/2021.

Facility has a log for each fire drill being conducted. Per licensee’s log, last drill was conducted on September 14, 2019. Children's files and adult files were reviewed. Children's files are current and complete. LPA reviewed the identification and emergency information form for every child for proper names and numbers filled. LPA encourages the facility to frequently visit our website at www.ccld.ca.gov for licensing regulations and new updates. Safe Sleep Regulation, Safe Sleep Environment and SIDS handouts were provided to the Licensee.

>No deficiencies were cited today under Title 22 Division 12 of the California Code of Regulations.
This report and rights to comment and appeal were discussed with staff. 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.
Facility 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: 11/08/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2019
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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