384001783-2-16-2023-05-CC-JYEE-CP4QD5-20230216110411

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 384001783
Report Date: 02/16/2023
Date Signed: 02/16/2023 11:04:27 AM

Document Has Been Signed on 02/16/2023 11:04 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 CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	DOMINGO, KARINA EME		FACILITY NUMBER:	384001783
ADMINISTRATOR:	KARINA DOMINGO		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(415) 494-5317
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94112
CAPACITY:	14	CENSUS: 5	DATE:	02/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Domingo, Karina		TIME COMPLETED:	11:30 AM

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) Yee conducted an Unannounced Required - 1 Year inspection today. The purpose of the inspection was explained. LPA met with Karina Domingo, her mom and 2 children upon arrival. Then 3 children arrived. Total census during the inspection was 5 children (4 infants). The doorbell is not functioning. The facility needs to fix it. The facility phone numbers and email address was verified with Karina. She said both phone numbers and the email are correct. LPA tried to reach her a few times via phone calls and email, was not successful. The facility personnel summary report was reviewed with Karina and current. Current residents are licensee, Karina, and her husband. The facility operation hours are Monday - Friday, 8:00 am - 5:30 pm. Daycare area: family room, kitchen, dining room, bedroom #1 and backyard. The dining room is filled with flower arrangement. Karina said she is working on personal interest from a class and the flowers need to be delivered. The remaining areas of the home are off-limits. The home is ventilated properly. The home is equipped with a fully charged fire extinguisher size 2A10BC, a smoke detectors, and a carbon monoxide. Smoke detector and carbon monoxide are in working condition. There are no swimming pool or hot tub in the premises. All harmful objects such as sharp, chemicals, detergents, cleaning compounds, medication are made inaccessible to children in care. Kitchen/Bathroom cabinets/drawers have child protective locks in place making all sharp objects, toxic, cleaning products, household items are inaccessible to children. The last fire/emergency drill was conducted on 11/16/2022. The disciplinary policy was discussed with Licensee today. The home has age-appropriate toys and equipment available for the children in care. LPA reviewed the children's files. continue to the next page.

SUPERVISOR'S NAME: Ali Zebila	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jennifer Yee	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: DOMINGO, KARINA EME	FACILITY NUMBER: 384001783
	VISIT DATE: 02/16/2023

NARRATIVE

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Licensee’s CPR and 1st aid certificate is current until 02/2025.

LPA discussed Child Abuse Mandated Reporter Training AB1207 with Licensee. As of January 1, 2018, all staff will be required to complete Child Abuse Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com. Certificate for the licensee and helper (mom) was not available during the inspection. Karina said her AB1207 has been expired and she will renew the class online together with her mom.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Sections 102417. When any IMS is provided, an updated Plan of Operation that includes 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) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, Available at: http://www.ada.gov/childqanda.htm

LPA discussed the safe sleep regulations with the licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment. LIC9227 "Individual Infant Sleeping Plan" and Infant sleep log was explained and provided.

Notice of Site Visit posted and shall remain posted for 30 days.

SUPERVISOR'S NAME: Ali Zebila	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jennifer Yee	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/16/2023 11:04 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 CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: DOMINGO, KARINA EME	FACILITY NUMBER: 384001783
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102416.1(a)

Personnel Records

(a) Personnel records shall be maintained on each employee and shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. The facility needs to submit helper (mom) immunization by due date.
	POC Due Date: 03/09/2023
	Plan of Correction
1 2 3 4

Type B

Section Cited

CCR

102416.3(a)(6)

Alterations to Existing Building or Grounds

(a) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following: (6) Any change from an area of the family child care home previously identified as "off limits" to an area where care and supervision will be provided to children in care. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the dinning areas (daycare areas) is filled with flowers arrangement which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/21/2023
	Plan of Correction
1 2 3 4	The facility needs to clear it out for the daycare. Photos maybe submitted.

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: Ali Zebila	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jennifer Yee	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/16/2023 11:04 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 CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: DOMINGO, KARINA EME	FACILITY NUMBER: 384001783
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(d)(1)

Infant Safe Sleep

The provider shall place infants up to 12 months of age on their backs for sleeping. This requirement shall not apply if the infant has a medical exemption from a licensed physician that allows for an alternative sleep position. The exemption shall be attached to the Individual Infant Sleeping Plan [LIC 9227 (3/20)] and contain the following criteria: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/02/2023
	Plan of Correction
1 2 3 4	The faciity needs to submit to CCL by due date.

Type B

Section Cited

CCR

102425(j)(2)(D)

Infant Safe Sleep

Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/02/2023
	Plan of Correction
1 2 3 4	Infants sleep log needs to be submitted by due date.

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: Ali Zebila	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jennifer Yee	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023

LIC809 (FAS) - (06/04)

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