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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384000529
Report Date: 04/18/2024
Date Signed: 04/18/2024 11:18:42 AM


Document Has Been Signed on 04/18/2024 11:18 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
SAN BRUNO CC RO, 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: 3DATE:
04/18/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Ana FernandezTIME COMPLETED:
11:25 AM
NARRATIVE
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On 4/18/2024 at 8:40AM., Licensing Program Analyst (LPA), Luis Gomez met with Licensee, Ana Fernandez. The purpose of the visit was explained and was for an Unannounced/ Random Inspection. Present was the licensee and 2 assistants caring for 3 children. All children present were infant-age. Adults present have criminal record clearances on file. Per licensee, the days and hours of operations are: Monday- Friday 8:00 AM.- 5:00 PM. The areas of the home designated for childcare are: Lower Level: Playroom #1; Bedroom #1; Bedroom #2; Bathroom #1; Backyard Area; and Gated Front Yard. The areas of the home designated as off- limit are: Lower Level: Garage, Entire Second level: Bedroom #3, #4; Bathroom #2; Kitchen; and Living Room. LPA inspected home for health and safety hazards.

At 8:45AM., the following was observed: Facility was clean and orderly with age-appropriate playthings available for the children. Floor and ground surfaces were clear of any obstructions or hazards. Accessible toys, puzzles and books were in good repair. For food services, facility has wide- based feeding chairs. LPA observed a table and several chairs, scaled to the proper size. Bathroom #1 was maintained clean with fixtures in operating condition. Facility was the proper temperature with ventilation and adequate lighting.

For scheduled nap, LPA observed infant play pens and beds in bedrooms #1 and #2. The play pens inspected were equipped with tight fitting mattress and sheets. Per licensee, napping linens are washed every week. The off-limit areas of the home have been made inaccessible. Detergents, cleaning compound, toxins and items which pose a danger have been stored inaccessible to children. Licensee’s home had functioning telephone service; carbon monoxide/ smoke detector combination detector; and fire extinguisher: 2A:10BC. First aid kit was reviewed during inspection.

At 9:05AM., LPA inspected licensee’s backyard and gated front yard areas. Areas were completely enclosed with turf installed for added safety. Home does not have any pools, fishpond, jacuzzi, or bodies of water.

LPA reminded licensee to remove accessible chairs with peeled paint. Advisory Note: Technical Violation (LIC9102TV) was issued.


(REFER TO 809c, FOR CONT)
SUPERVISOR'S NAME: Marie RodriguezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024
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 6


Document Has Been Signed on 04/18/2024 11:18 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: FERNANDEZ, ANA M.
FACILITY NUMBER: 384000529

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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At 9:30AM., Based on record review, LPA confirmed licensee has not competed required 'Mandated Reporter Training' (AB1207). This poses a potential health and safety risk to children in care.
POC Due Date: 05/03/2024
Plan of Correction
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Licensee and helpers (2) will complete required 'Mandated Reporter Training' course (AB1207) by the due date: 5/3/2024.
This proof of correction will be submitted to LPA via email.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Marie RodriguezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: FERNANDEZ, ANA M.
FACILITY NUMBER: 384000529
VISIT DATE: 04/18/2024
NARRATIVE
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(Page 2)
At 9:25AM., LPA reviewed the facility records including children’s and personnel files. Licensee’s personnel files were reviewed and included staff: Proof of required Immunization; Acknowledgement to Report Suspected Child Abuse (LIC9102); and Notice of Employee Rights (LIC9052).

At 9:30AM., Based on record review, LPA confirmed licensee has not competed required 'Mandated Reporter Training' (AB1207).

The children’s files were reviewed and included: Identification and Emergency Information (LIC700); Consent for Medical Treatment (LIC627); Notification of Parent’s Rights (LIC995); Health History; and Immunization Records.

Licensee is documenting napping conditions every 15 minutes for infant-age children in care.

Licensee’s Cardiopulmonary Resuscitation/ First Aid Certification (CPR) was current, expiring: 6/2025.

Required emergency disaster drill was conducted during inspection (4/18/2024) and logged by the licensee.

The required forms are posted in facility, including the Facility License, Notification of Parent’s Rights (PUB379), and Emergency Disaster Plan.

Per licensee, isolation of an ill child is in the playroom. Per licensee, the program provides families with snack and lunch services.


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

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: FERNANDEZ, ANA M.
FACILITY NUMBER: 384000529
VISIT DATE: 04/18/2024
NARRATIVE
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(Page 3)
Licensee was reminded that all adults 18 years and over living in the home, person who provides care and supervision to children, and staff who have contact with children, including employee and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.

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.

Licensee was informed of the www.mychildcareplan.org site is a consumer education website that helps families obtain child care by connecting to child care providers and resources and referral agencies (R&R) throughout California.

Incidental Medical Services (IMS) policy was discussed. For IMS information, see PIN 20-02-CCP. When an IMS is provided, a plan for IMS must be submitted to the department. the following information regarding ADA was provided: US Department of Justice (USDOJ) toll- free ADA information line at (800) 514-0301 (voice)/ (800) 514- 0382 (TTY) and link to publications: Commonly asked questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm
(REFER TO 809c, FOR CONT.)
SUPERVISOR'S NAME: Marie RodriguezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
LIC809 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: FERNANDEZ, ANA M.
FACILITY NUMBER: 384000529
VISIT DATE: 04/18/2024
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(Page 4)
To improve the quality and value of the new inspection process, a survey may 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, deficiencies were observed in areas evaluated according to California Title 22, Div. 12 Chap. 3, Health and Safety, Code of Regulations and cited on 809D. Exit interview including the plan for correction; and facility evaluation report was reviewed with Licensee, Ana Fernandez. Licensee’s signature of this form acknowledges the receipt of these documents.

During exit interview, licensee, Ana Fernandez confirmed that there are no registered sex offenders living in the facility, and LPA completed the RSO profile. Notice of site visit was given and must remain posted for 30 days.

This report must be available in the facility for public review. Notice was provided and shall remain posted for 30 days. The licensee was advised for additional questions to call CCL Office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website: www.ccld.ca.gov

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

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
LIC809 (FAS) - (06/04)
Page: 5 of 6