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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384002634
Report Date: 02/14/2024
Date Signed: 02/14/2024 11:58:02 AM


Document Has Been Signed on 02/14/2024 11:58 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:BUSTILLO, FLOR MARIAFACILITY NUMBER:
384002634
ADMINISTRATOR:BUSTILLO, FLOR MARIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 410-7785
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94110
CAPACITY:14CENSUS: 8DATE:
02/14/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Flor BustilloTIME COMPLETED:
12:10 PM
NARRATIVE
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On 2/14/2024 at 8:45AM., Licensing Program Analyst (LPA), Luis J. Gomez met with Licensee, Flor Bustillo. The purpose of today’s visit was explained and was for an unannounced, annual random Inspection. Present was the licensee and two assistants caring for 8 children (4 Infant-age, 4 Preschool- age). Licensee’s home is a two bedroom, one bathroom, one level unit. Licensee’s days and hours of operation are: Monday- Friday: 8:00am- 4:00pm. The areas of the home used for care are: Living Room (Playroom); Kitchen; Hallway; Bathroom; and Bedroom #1 (Napping Only). The areas of the home designated as off- limit are: Laundry Area; Backyard; and Bedroom #2. LPA inspected home for health and safety hazards.

At 8:50AM., the following was observed: Facility was clean, orderly with age-appropriate playthings available for the children. Accessible furniture, toys, and books inspected were in good repair. Cubbies and hangers are available for storage of belongings. The facility kitchen has child- sized tables and chairs. LPA observed legs of infant feeding chairs are wide based. For nap services, LPA observed several infant play pens and napping mats are located in playroom and bedroom #1. Infant playpen were equipped with tight-fitting sheets. Per licensee, she washed napping sheets once per week. Facility bathroom is located next to the kitchen, and was observed clean, with supplies for hand washing. Diaper changing table is available in playroom. Per licensee, changing table is disinfected after each use. The facility was a comfortable temperature with ventilation and lighting. Off-limit areas have been made inaccessible with installed safety gates and locked doors. Home had functioning telephone service; carbon monoxide detector; smoke detector; and fire extinguisher: 3A:40:BC.

Home does not have any pools, fishponds, jacuzzi, or bodies of water.


(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: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024
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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Document Has Been Signed on 02/14/2024 11:58 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: BUSTILLO, FLOR MARIA
FACILITY NUMBER: 384002634

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
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: Time of each 15-minute check

This requirement is not met as evidenced by:
Deficient Practice Statement
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At 10:00AM., Based on record review and interview; LPA confirmed licensee is not documenting infant napping condition during each 15-minute review. This poses a potential health and safety risk to children care.
POC Due Date: 02/16/2024
Plan of Correction
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Licensee will begin documenting infant napping conditions, during each 15 minutes review, by the due date: 2/16/2024.

Proof of correction will be submitted to the Department 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: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024
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 CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: BUSTILLO, FLOR MARIA
FACILITY NUMBER: 384002634
VISIT DATE: 02/14/2024
NARRATIVE
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(Page 2)
At 9:40AM., LPA reviewed facility records including the children’s files and staff files. The staff files were reviewed and included the: Notice of Employee Rights (LIC9052); ‘Mandated Reporter Training’ certifications; and Acknowledgement to Report Suspected Child Abuse (LIC9108). LPA reminded licensee to ensure all staff’s proof of immunization are stored in the facility records. Advisory Note: Technical Violation (LIC9102TV) was issued.

Children’s files were reviewed and included the: Notification of Parent’s Rights (LIC995); Affidavit Regarding Liability Insurance (LIC282); Notice of Additional Children in are (LIC9150); and Immunization Records.

At 10:00AM., Based on record review and interview; LPA confirmed licensee is not documenting infant napping condition during each 15-minute review.

Licensee’s Cardiopulmonary Resuscitation/ First Aid Certification (CPR) was current, expiring: 1/2026.
Licensee’s ‘Mandated Reporter Training’ was current, expiring: 12/2025.

Licensee is conducting emergency disaster drill every 6 months with last drill completed on 9/20/2023, properly logged. Per licensee, next emergency drill will be done prior to 3/20/2024.

The required forms are posted in facility, including the Facility License; Notification of Parent’s Rights (PUB379); and the Emergency Disaster Plan (LIC610A). Earthquake preparedness checklist (LIC9148) was provided during inspection.

Per licensee, isolation of an ill child is in the playroom. Per licensee, she provides food service for children in care. LPA advised licensee to ensure all children’s food containers brought by families are be labeled. Advisory note: Technical Violation (LIC9102) 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: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
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: BUSTILLO, FLOR MARIA
FACILITY NUMBER: 384002634
VISIT DATE: 02/14/2024
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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 the 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

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, Plan for correction, and Facility Evaluation Report was reviewed with Licensee, Flor Bustillo. Licensee’s signature of this form acknowledges the receipt of these documents.

During exit interview, licensee, Flor Bustillo 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.
SUPERVISOR'S NAME: Marie RodriguezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
LIC809 (FAS) - (06/04)
Page: 5 of 6