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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410517464
Report Date: 11/06/2019
Date Signed: 11/06/2019 01:47:58 PM

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:BUCKNER, VERONICA & SMITHFACILITY NUMBER:
410517464
ADMINISTRATOR:BUCKNER, VERONICAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 323-4374
CITY:EAST PALO ALTOSTATE: CAZIP CODE:
94303
CAPACITY:12CENSUS: 1DATE:
11/06/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Licensee, Veronica BucknerTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA), Cindy Interiano, met with Licensee, Veronica Buckner. Purpose of the inspection was explained and was for an Annual/Random inspection. Present in the facility is Licensee caring for 1 PreK child. Licensee owns home, which is a 2 bedroom, 1 bathroom, single level house. Facility was inspected and Daycare areas are: Living Room, Bathroom #1, Playroom, and Backyard. Off Limit areas are: Bedroom #1, Bedroom #2, Dining Area, and Kitchen. All off limit areas are properly barricaded. LPA observed the following: Daycare area is clean, orderly, and equipped with age appropriate toys and equipment for the children. Home has sufficient lighting and ventilation. Home has a working telephone, a working smoke and carbon monoxide detector, and a fully charged fire extinguisher. There is no fireplace or bodies of water in the daycare area. There are no poisons, detergents, or cleaning products accessible to daycare children. Licensee states there are no guns or weapons of any kind in the home. Licensee’s CPR expires in 03/2020. Licensee conducted last emergency drill on 09/16/19 and is properly logged. Licensee provides daily snacks and meals. Discipline policy is mainly redirection. All required postings are properly posted. Licensee has required proof of immunization on file and Mandated Reporter Training certificate on file. Children’s roster was reviewed and is complete and up to date.

See Page 2. . .
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2019
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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: BUCKNER, VERONICA & SMITH
FACILITY NUMBER: 410517464
VISIT DATE: 11/06/2019
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See Page 2. . .

During inspection,
*Incidental Medical Services (IMS) policy was discussed.
*Licensee was reminded about having all Staff and Volunteers provide proof of immunization against influenza, pertussis, and measles or qualifies for an exemption.
*Licensee was reminded about the Provider Information Notices (PINs) on CCLD website.
*Licensee was reminded about Mandated Reporter Training available on CCLD website
(www.ccld.ca.gov or www.mandatedreporterca.com).
*Licensee was advised of the new Lead Bill (effective 01/01/19), requiring Facilities to distribute a two-page flyer to Guardians with information on lead poisoning facts
*Licensee was given information regarding ‘Safe Sleep’ practices.

>No deficiencies were issued today under Title 22 Division 12 of the Ca. Code of Regulations.

>This report and rights to comment and appeal were discussed with Licensee. This report must be available in the facility for public review. Notice of site visit was observed being posted.
Licensee was advised any additional questions to call Office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website: www.cdss.ca.gov
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2019
LIC809 (FAS) - (06/04)
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