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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384000529
Report Date: 11/07/2019
Date Signed: 11/07/2019 11:45:37 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:FERNANDEZ, ANA M.FACILITY NUMBER:
384000529
ADMINISTRATOR:FERNANDEZ, ANA M.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 641-8711
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94110
CAPACITY:14CENSUS: 8DATE:
11/07/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Licensee, Ana Fernandez TIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA), Luis J. Gomez met with Licensee, Ana Fernandez. Purpose of the inspection was explained and was for an unannounced annual inspection. Present in the facility is the Licensee and helper caring for 8 children. (4 infants, 4 Preschool aged). Child care is provided in the downstairs area of the home. All of the adults in the home have their criminal record clearance on file. Licensee is within capacity limits of the large license. Licensee’s home is a 2 - bedroom, 2 - bathroom 2 -level house. Hours of Operation are: Mon- Fri: 8:00am- 5:30pm. Daycare areas are: Downstairs: Playroom, Toddler room, Baby room, Outdoor Play Area, Front Yard and Bathroom #1. Off Limit areas are: Entire Upstairs Area: Bedroom #1, Bedroom #2, Bathroom #2, Kitchen and Living room. LPA Gomez toured the home with the licensee and inspected for health and safety hazards.

At 9:50am on November 7, 2019 LPA inspected facility playroom, outdoors play area, bathroom #1. LPA observed playroom has plenty of age appropriate toys, puzzles and materials for the children. There are several child size tables and chairs available for activities. All outlets in the day-care area are properly covered. Licensee has installed child safe gates, making all off limit areas inaccessible. Bathroom #1 is equipped with 2 toilets for a diaper changing table. LPA observed bathroom is maintained clean and stocked with diapers and supplies for the children. Outdoor play area, is partially covered and has toys, blocks and equipment that are in good repair. Licensee has installed soft padding on the floor and pillars for increased safety. Outdoor play area has 2 shed for extra storage. Licensee stated outdoor sheds remain locked during day care hours.

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

DATE: 11/07/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2019
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: FERNANDEZ, ANA M.
FACILITY NUMBER: 384000529
VISIT DATE: 11/07/2019
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At 10:00am on November 7, 2019 LPA inspected facility toddler room, baby room and front yard. Toddler room and baby room are orderly and equipped with beds and sleeping bags for the children. The baby room, located in the hallway, is equipped with 3 baby cribs and a fully stocked diaper changing table. Licensee stated she washes the children’s blankets once a week. Home has ample lighting and ventilation throughout. Front yard is enclosed with fencing and has a slide and a play structure for the children. At 10:05pm on November 7, 2019 LPA Gomez observed a broken chair in the front yard, accessible to children in care. Home has a working telephone, a smoke detector, carbon monoxide detector, and a fully charged fire extinguisher (3A40BC). 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: 02/2021

At 11:00am on November 7, 2019 LPA reviewed children’s files, facility roster and personnel files during today’s inspection. LPA observed licensee is conducting emergency disaster drills, with the last drill done September 10, 2019, properly logged. Licensee stated she provides all daily snacks and meals for children in care. All required postings are properly posted next to the main door. LPA observed a pet dog in the home. Licensee stated pet is kept in the off-limits area.

During today's 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.

Based on today’s inspection, there are no deficiencies observed and cited according the Title 22 Division 12 of Ca. Code of Regulations. An exit interview was conducted and a copy of the report was provided to Ana Fernandez's, and signature of this form acknowledges the receipt of these documents.

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) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2019
LIC809 (FAS) - (06/04)
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