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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384002634
Report Date: 06/10/2022
Date Signed: 06/10/2022 04:42:46 PM


Document Has Been Signed on 06/10/2022 04:42 PM - 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:BUSTILLO, FLOR MARIAFACILITY NUMBER:
384002634
ADMINISTRATOR:BUSTILLO, FLOR MARIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 410-7785
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94110
CAPACITY:14CENSUS: 9DATE:
06/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Flor Bustillo, America BarajasTIME COMPLETED:
04:50 PM
NARRATIVE
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On June 10, 2022, at 1:20PM., Licensing Program Analyst (LPA), Luis J. Gomez met with Helper, America Barajas. Purpose of the inspection was explained and was for an unannounced; Annual/ Random inspection. Present in facility was were two helpers caring for nine children (8 preschool age, 1 infant age). Licensee arrived during inspection. Adults present had their criminal record clearances on file. Licensee’s home is a two bedroom, one bathroom, one level unit. Days and hours of operation are Monday- Friday, 8:00 AM. to 5:00 PM. Day-care Area are: Living room (Playroom), Kitchen/ Dining Area, Bathroom #1 and Bedroom #1 (napping only) Off-limit Area are: Laundry Area (Pass through only) and Bedroom #2. LPA inspected entire home with licensee for health and safety hazards.

At 1:25PM, the following was observed: day-care was kept clean, orderly, and with age appropriate playthings available for the children. Furniture and materials inspected were in good repair. Kitchen/ Dining Area had child size table and chairs for snack and activities. Facility had several cubbies for storage of children’s belongings. Floor in playroom had a padded surface for added safety. Playroom was equipped with diaper changing table. For napping services, several play pens are stored in the playroom and in bedroom #1. Mattresses inspected were the proper size and equipped with tight-fitting sheet. Facility had at least one crib available for each infant in care. Bathroom #1 was observed clean with supplies available for handwashing. Bathroom fixtures tested were in operating condition. Off-limit areas were made inaccessible with child safety gates. Outlets and trash bins had been properly covered. Items which could pose a danger including; detergents, compounds, wipes and spray bottles, were stored inaccessible to day-care children. Facility was the proper temperature with adequate ventilation and lighting. Home had functioning cell phone, smoke detector, carbon monoxide detector and one, fully charged, fire extinguisher (4A:60BC).

Home did not have any swimming pools, spas, hot tubs, fishponds or other bodies of water. Per licensee, home does not have any guns for weapons.


(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: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2022
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


Document Has Been Signed on 06/10/2022 04:42 PM - 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: BUSTILLO, FLOR MARIA
FACILITY NUMBER: 384002634

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, LPA confirmed personnel files, S1,S2, missing required proof of immunization. This poses a potential health and safety risk to children in care.
POC Due Date: 06/30/2022
Plan of Correction
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Licensee will submit proof of correction the Department by the due date: 6/30/2022. Proof of correction will be submitted 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: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2022
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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: BUSTILLO, FLOR MARIA
FACILITY NUMBER: 384002634
VISIT DATE: 06/10/2022
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(Page 2)
At 2:20PM., LPA reviewed the facility and children’s records. Children's records were reviewed and included, (LIC700) Identification of Emergency Information, (LIC624) Consent for Medical Treatment, (LIC9151) Notification of Additional Children in Care, (LIC995A) Notification of Parent’s Rights, Affidavit Regarding Liability Insurance and Immunization Record.

Licensee had the 'Individual Infant Sleeping Plan' (LIC9224) for qualifying infant's in care.

At 2:45PM., Based on record review and interview, LPA confirmed licensee is not maintaining infant napping log, with documentation for each 15-minute check. During inspection, Advisory Note: Technical Assistance (LIC9102TA) was issued.

At 3:00PM., Based on record review and interview, LPA confirmed employee files, S1,S2 missing required proof of immunization.



Licensee's Cardiopulmonary Resuscitation (CPR)/ First Aid Certification was current, expiring on 1/2024. Licensee's Mandated Reporter Training Certification (AB1207) was current expiring 6/1/2024.

Licensee is conducting and documenting required emergency disaster drills every six month; last drill was completed on 3/6/2022.

LPA observed required posting in entry way including: Childcare License, Notification of Parent’s Rights (LIC995A) and Emergency Disaster Plan (LIC610A) in visible location. Children's Roster (LIC500) was current. Per licensee, isolation of an ill child is in the playroom.

Per licensees, no children present require incidental medical services (IMS) at this time. Per licensees, parent’s provides lunch and snack items for children in care. LPA asked staff to ensure all children’s food containers brought to facility by families are properly labelled.


(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: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022
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: BUSTILLO, FLOR MARIA
FACILITY NUMBER: 384002634
VISIT DATE: 06/10/2022
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(Page 3)
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.

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, deficiencies were observed in areas evaluated, according to California Title 22, Health and Safety Code of Regulations and cited on 809D. Exit interview and plan of correction was discussed with Licensee Flor Bustillo, and signature of this form acknowledges receipt of these documents.

Notice of Site Visit was provided and must be posted for 30 days.

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. Website

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

DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5