<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384003070
Report Date: 06/29/2022
Date Signed: 06/29/2022 12:47:37 PM


Document Has Been Signed on 06/29/2022 12:47 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:ROSILLO, ANGELINA A.FACILITY NUMBER:
384003070
ADMINISTRATOR:ROSILLO, ANGELINA A.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 418-8563
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94110
CAPACITY:14CENSUS: 10DATE:
06/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Angelina Rosillo TIME COMPLETED:
12:55 PM
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
On 6/29/2022 at 8:45AM., Licensing Program Analyst (LPA), Luis J. Gomez met with Licensee, Angelina Rosillo. Purpose of the inspection was explained and was for an unannounced; Annual Random inspection. Present in facility was the licensee and two helpers caring for 10 children (three infant age, seven preschool age). Licensee’s home is a three bedroom, two bathroom, two level house. Days and hours of operation are Mon- Fri, 8:00- 5:30pm. Daycare areas are: 1st Floor Living Room (playroom); Bathroom #1; Bedroom #1 (Napping Only); Dining Area; and Outdoor Play Area. Off Limit areas are: 1st Floor: Kitchen (Pass through only) and Entire 2nd Floor: Bedroom #2; and Bathroom #2. LPA inspected entire home, inside and outside, with licensee for health and safety hazards.

At 9:00AM., the following was observed: day-care was clean, orderly, and with age appropriate playthings available for the children. Furniture and materials inspected were in good repair. Dining Area had child sized table with chairs for snack and activities. Individual cubbies were in entry way for added storage. For napping services, cots and cribs were available in bedroom #1. Per licensee, napping supplies are washed every week. Licensee has one available crib for each infant in care; each crib had tight fitting sheets. LPA reminded licensee to ensure daily schedule provides opportunity for day-care children to engage in quiet rest/ napping.

At 9:07AM., Based on observations, LPA confirmed infant mattress in play pen was not the proper size. Advisory Note: Technical Assistance (LIC9102TA) was issued.

Bathroom #1, located next to kitchen, was clean with adequate supplies. Bathroom fixtures were in operating condition. Off-limit areas had been made inaccessible with child safety gates. Outlets and trash bins had been covered. Detergents, cleaning compounds, wipes, spray bottles, and other items which could pose a danger, were stored inaccessible to children. Facility was the proper temperature, with adequate ventilation. LPA advised licensee to install added lighting in bedroom #1. Home had functioning telephone; smoke/ carbon monoxide detector combo; and one, fully charged, fire extinguishers (2A:10BC). (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: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2022
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 06/29/2022 12:47 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: ROSILLO, ANGELINA A.
FACILITY NUMBER: 384003070

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2022

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
1
2
3
4
Based on interview and record review, LPA confirmed licensee's mandated reporter training certification (AB1207) is expired. This poses a potential health and safety risk to children in care.
POC Due Date: 07/08/2022
Plan of Correction
1
2
3
4
Licensee and will update the required mandated reporter training certification (AB1207) by the due date: 7/8/2022.

Proof of correction will be submitted to the Department via email.
Type B
Section Cited
CCR
102370(d)(1)
Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observations and record review, LPA confirmed staff member, S2, assisting without proper criminal record clearance on file. This poses a potential health and safety risk to children in care.
POC Due Date: 07/08/2022
Plan of Correction
1
2
3
4
Licensee will ensure staff member, S2, receives properly criminal record clearance prior to working with day-care children.

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: 06/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2022
LIC809 (FAS) - (06/04)
Page: 2 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: ROSILLO, ANGELINA A.
FACILITY NUMBER: 384003070
VISIT DATE: 06/29/2022
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
26
27
28
29
30
31
32
(Page 2)
At 9:20AM, LPA inspected the outdoor play area. Outdoor area was completely enclosed. All playthings inspected where in good repair. Outdoor area had shading for the children. Home does not have any swimming pools, spas, hot tubs, fishponds or other bodies of water.

At 9:30AM., LPA reviewed the facility and children’s records. Facility records were reviewed and included staff's: Criminal Record Statement (LIC508); Notice of Employee Rights (LIC9052); and Statement to Report Suspected Child Abuse (LIC9108). LPA reminded licensee to store proof of required immunization in facility records.

At 9:45AM., Based on interview and record review, LPA confirmed licensee's mandated reporter training certification (AB1207) is expired.

At 10:00AM., Based on observations and record review, LPA confirmed staff member, S2, present without proper criminal record clearance on file.

Children's records were reviewed and included: Identification of Emergency Information (LIC700); Consent for Medical Treatment (LIC627); Health History (LIC702); Immunization Records; Notification of Parent’s Rights (LIC995A); and Signed 'Individual Infant Sleeping Plan', (LIC9227) for qualifying infant in care.

Licensee is maintaining required infant napping logs for each 15-minute check.

Licensee’s Cardiopulmonary Resuscitation (CPR)/ First Aid Certification was current, expiring on 9/2022.

Licensee is conducting emergency disaster drills every six months; with last drill completed on 6/17/2022, properly logged.

LPA observed required posting, including: Facility License; Notification of Parent’s Rights; and Emergency Disaster Plan (LIC610A). Children's Roster (LIC500) was reviewed during inspection. Per licensee, isolation of an ill children is in playroom.

Per licensee, facility provides all lunch and snack for children in care. LPA asked licensee to ensure all children’s food containers brought to facility by families are properly labelled. Per licensee, home does not have any firearms. (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: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022
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: ROSILLO, ANGELINA A.
FACILITY NUMBER: 384003070
VISIT DATE: 06/29/2022
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
26
27
28
29
30
31
32
(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 the LIC809D. Exit interview and plan of correction was discussed with Licensee, Angelina Rosillo, 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: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5