410518784-10-16-2023-05-CC-LGOZ-CWNVCC-20231016161855

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 410518784
Report Date: 10/16/2023
Date Signed: 10/16/2023 04:19:01 PM

Document Has Been Signed on 10/16/2023 04:19 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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	CAPOVILLA, LUCY		FACILITY NUMBER:	410518784
ADMINISTRATOR:	CAPOVILLA, LUCY		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(650) 703-5454
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94402
CAPACITY:	14	CENSUS: 4	DATE:	10/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Lucy Capovilla		TIME COMPLETED:	04:25 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 10/16/2023 at 2:10PM., Licensing Program Analysts (LPA), Luis J. Gomez met with Licensee, Lucy Capovilla. Purpose of the inspection was explained and was for an Unannounced; Annual Random. Present was the licensee caring for four children (3 infant age, 1 preschool age). Adults have criminal record clearances on file. Licensee’s home is a 3 bedroom, 2 bathroom, 1 level house. The days and hours of operation are Monday- Friday, 7:00- 5:30pm. Day-care Areas are: Living Room (Playroom); Bedroom #1 (Napping Only); Bedroom #2 (Napping Only); and Bathroom #1. Off-limit areas are: Backyard Area; Garage; Kitchen; Bedroom #3; and Dining Room (Pass through only). LPA inspected home, inside and outside, with licensee for health and safety hazards. At 2:15PM., the following was observed: Facility was clean and orderly, with age-appropriate playthings available for the children. Floors/ground surfaces was clear of obstructions. Accessible furniture, toys and books inspected were in good repair. Playroom has child sized tables and chairs for snack and seated activities. For napping services, LPA observed playpen located in Playroom; Bedroom #1; and #2. Play pens inspected had properly sized mattress. LPA reminded licensee to ensure play pen have tight-fitting sheets installed. The off-limit area has been made inaccessible with child safety gate. Bathroom #1 was clean with supplies for hand washing. Facility was the proper temperature with ventilation and lighting. Home had functioning telephone service; smoke/ carbon monoxide combination detector; and fire extinguisher: 3A:40:BC, located in kitchen. Facility does not have any pools, fishponds, or other bodies of water. (REFER TO 809C, FOR CONT)

SUPERVISOR'S NAME: Marie Rodriguez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis Gomez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023

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 3

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: CAPOVILLA, LUCY	FACILITY NUMBER: 410518784
	VISIT DATE: 10/16/2023

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 2:55PM, LPA reviewed facility and children’s records.

Children’s files were reviewed and included the: Notification of Parent's Rights (LIC995); Identification of Emergency Information (LIC702); Individual Infant Sleeping Plans (LIC9227); Immunization Record; and Consent for Medical Treatment (LIC627).

LPA advised licensee maintaining napping logs, documenting each 15- minute review for infants in care.

Licensee's Cardiopulmonary Resuscitation (CPR)/ First Aid certification was current, expiring: 3/2025.
Licensee’s 'Mandated Reporter Training' (AB1207) certification was current, expiring: 2/2024.

Licensee is conducting and emergency disaster drills every six months, with last drill completed on: 10/13/2023, properly logged.

Required forms are posted in facility, including the Childcare License; Notification of Parent’s Rights (PUB379); Emergency Disaster Plan (LIC610A); Earthquake Preparedness Checklist.

Per licensee, isolation of an ill children is in the playroom.

Per licensee, families provides food service for children in care. LPA advised licensee to ensure all children’s food containers brought by families are be labeled. Per licensee, home does not have any firearms.

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. (REFER TO 809C, FOR CONT.)

SUPERVISOR'S NAME: Marie Rodriguez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis Gomez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: CAPOVILLA, LUCY	FACILITY NUMBER: 410518784
	VISIT DATE: 10/16/2023

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)
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.

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, no deficiencies were observed in areas evaluated according to California Title 22, Div. 12 Chap. 3 Health and Safety Code of Regulations. LPA conducted exit interview, including report was discussed with licensee, Lucy Capovilla. Licensee’s signature of this form acknowledges the receipt of these documents.

During exit interview, licensee, Lucy Capovilla 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 Rodriguez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis Gomez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3