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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384000529
Report Date: 11/23/2022
Date Signed: 11/23/2022 10:53:06 AM


Document Has Been Signed on 11/23/2022 10:53 AM - It Cannot Be Edited

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: 5DATE:
11/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Ana FernandezTIME COMPLETED:
11:05 AM
NARRATIVE
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On 11/23/2022 at 8:20AM., Licensing Program Analyst (LPA), Luis J. Gomez met with Licensee, Ana Fernandez. Purpose of the inspection was explained and was for an unannounced; Annual Random inspection. Present in facility was the licensee and helper caring for five children (2 infant age, 3 preschool age). Adults present have criminal record clearances on file. Licensee’s home is a four bedroom, two bathroom, two level house. Days and hours of operation are Monday- Friday, 7:30AM- 5:00PM. Daycare areas are: Lower Level: Playroom #1; Bedroom #1; Bedroom #2; Bathroom #1; Backyard Area; and Gated Front Yard. Off Limit areas area: Lower Level: Garage, Entire Second level: Bedroom #3, #4; Bathroom #2; Kitchen; and Living Room. LPA inspected home, inside and outside, with licensee for health and safety hazards.

At 8:25AM., the following was observed: Facility was clean, orderly, with age appropriate playthings available for the children. Ground surfaces was clear of obstructions. Accessible furniture, toys and books inspected were in good repair. Playroom and Backyard area have child sized table and chairs for snack and seated activities. Facility is equipped with cubbies for storage of belongings. For napping services, LPA observed several beds, and playpens, located in bedroom #1, #2. Per licensee bedrooms are used for napping only. LPA observed one crib available (with clean/tight fitting sheet) for each infant-age child in care. Bathroom#1 had adequate supplies for hand-washing. Fixtures tested were in operating condition. Detergents, cleaning supplies, toxins and compounds, and items which pose a risk, have been made inaccessible. Facility was the proper temperature, with ventilation and lighting. Home had functioning telephone; smoke/ carbon monoxide combination detector; and one fire extinguisher, 2A:10BC.

At 8:45, LPA inspected the outdoor play areas. Backyard area and front yard are completely enclosed with tall fencing. Playthings inspected were in proper repair. Home does not any pools, fishponds, or bodies of water on the premises. Shed was reviewed during inspection. Licensee has two dogs in home. Per licensee dogs have proper vaccination and remain in the off limit area.


(REFER TO 809C, FOR CONT)
SUPERVISOR'S NAME: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 11/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/23/2022
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 5


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: 11/23/2022
NARRATIVE
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(Page 2)
At 9:00AM, LPA reviewed facility and five children’s records. Children files were reviewed and included the: Identification of Emergency Information; Health History; Immunization Records; Consent for Medical Treatment; and Individual Infant Sleeping Plan (LIC9227) for qualifying infants.

LPA reminded licensee to maintain documentation of each 15- minute napping review, for all infant- age children in care. Advisory Note: Technical Assistance (LIC9102TA) was issued.

At 9:00AM., Based on interview and record review, LPA confirmed licensee has not completed required mandated reporter certification (AB1207). Advisory Note: Technical Assistance (9102TA) was issued during inspection.



Licensee’s Cardiopulmonary Resuscitation (CPR)/ First Aid certification is current, expiring: 6/2023
Licensee is conducting required emergency disaster drill, with last drill completed on 6/24/2022, properly logged.

Required posting are posted in visible location. Posting include Childcare License, Notification of Parent’s Rights (PUB379), and Emergency Disaster Plan (LIC610A).

Per licensee, isolation of ill children is in bedroom #1.

Per licensee, she provides all foods services for children in care. LPA reminded licensee to ensure all children’s food containers brought by families is properly labeled. Per licensee, home does not have any firearms or weapons.

Licensee was reminded that all adults 18 years and over, living or working in the home, including employee and volunteers, must obtain criminal clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/ day up to $500.00 maximum per day/ per person will be assessed if this regulation is violated.


(REFER TO 809C, FOR CONT.)
SUPERVISOR'S NAME: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: 11/23/2022
NARRATIVE
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(Page 3)
LPA discussed the safe sleep regulations with licensee and discussed Child Care Licensing Safe Sleep Web page at:https://www.cdss.ca.gov/inforesource/child-care-licesning/public-information-and-resources/safe-sleep as an additional resource. LPA informed licensee of the importance of checking for recalled infant devices on United States consumer Product Safety Commission (CPSC) website at http://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tool, please send them to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesource/community-care-licensing/inspection-process.

Based on today's inspection, no deficiencies were observed in areas evaluated according to California Title 22, Health and Safety Code of Regulations. Exit interview and report was discussed with Licensee, Ana Fernandez and signature of this form acknowledges receipt of these documents.



Notice of Site Visit was provided and must be posted for 30 days. Report was unable to print, Report will be mailed to licensee.

This report must be available in the facility for public review. Licensee was advised any additional questions to call Office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766.
SUPERVISOR'S NAME: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5