414001089-10-23-2019-05-CC-CINO-BH8NM5-20191023103435

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414001089
Report Date: 10/23/2019
Date Signed: 10/23/2019 10:34:52 AM

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:	MUNOZ, TERRI ANN		FACILITY NUMBER:	414001089
ADMINISTRATOR:	MUNOZ, TERRI ANN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(650) 834-0181
CITY:	SAN BRUNO	STATE: CA	ZIP CODE:	94066
CAPACITY:	14	CENSUS: 6	DATE:	10/23/2019
TYPE OF VISIT:	Annual/Required	UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Helper, Crystal Gonzalez		TIME COMPLETED:	10:50 AM

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	Licensing Program Analyst (LPA), Cindy Interiano met with Licensee’s Helper, Crystal Gonzalez. Licensee was at an appointment. Purpose of the inspection was explained and was for an Annual/Required inspection. Present in the facility is Helper caring for 6 children (3 infants and 3 PreK). Home is a 3 bedroom, 3 bathroom, two level home. Licensee rents home and lives with minor child. Facility was inspected and the Daycare areas are: lower level: Playroom #1, Playroom #2, Nap room, Bathroom #1, Deck, and Backyard. Off Limit areas are: lower level: Garage, and entire upper level: Living Room, Dining Room, Kitchen, Bedrooms #1, #2, #3, and Bathrooms #2 and #3. 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 detector, and a fully charged fire extinguisher. Daycare area has no chimney or bodies of water. There are no poisons, detergents, or cleaning products accessible to daycare children. Helper states there are no guns or weapons of any kind in the home. Licensee’s and Helper’s CPR expires in 03/2020. Last emergency drill was conducted on 08/14/19 and is properly logged. Children bring their own meals. Discipline policy is mainly redirection. All required postings are properly posted. Children’s roster is complete and up-to-date. Licensee and Staff have required proof of immunization on file. During inspection, LPA observed a ‘baby rocker seat’ and an ‘exersaucer’ in the daycare area. Also, LPA observed a carbon monoxide detector, however it was not plugged in and did not have a battery installed. See Page 2. . .

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2019

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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MUNOZ, TERRI ANN	FACILITY NUMBER: 414001089
	VISIT DATE: 10/23/2019

NARRATIVE

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During inspection, Helper was asked to remind/advise Licensee regarding:
>Annual Dues to be paid before due date.
*Incidental Medical Services (IMS) policy.
*having all Staff and Volunteers have proof on file of immunization against influenza, pertussis, and measles or qualifies for an exemption.
*Provider Information Notices (PINs) available on the CCLD website.
*Mandated Reporter Training available on CCLD website (www.ccld.ca.gov or www.mandatedreporterca.com)
*new Lead Bill (effective 01/01/19), requiring Facilities to distribute a two-page flyer to Guardians with information on lead poisoning facts
*information regarding ‘Safe Sleep’ practices.

>See attached page for deficiencies issued today under Title 22 Division 12 of the Ca. Code of Regulations.

>This report and rights to comment and appeal were discussed with Helper. This report must be available in the facility for public review. Notice of site visit was observed being posted.
Helper 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 Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2019

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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MUNOZ, TERRI ANN	FACILITY NUMBER: 414001089
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/23/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/28/2019 Section Cited	1 2 3 4 5 6 7	102417(g)(10) Operation of a Family Child Care Home. A baby walker or similar items are not permitted on the premises of a family child care home in accordance with H&S Code Sections 1596.846(b)&(c).
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: LPA’s observation of a ‘baby rocker seat’ and an ‘exersaucer’ in the daycare area. This poses a potential safety risk to children in care.	8 9 10 11 12 13 14	These items must be removed or placed in off limit area by due date.
Type B 10/28/2019 Section Cited	1 2 3 4 5 6 7	§1597.543 Carbon monoxide detectors required; inspection. Every family day care home for children shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.
	8 9 10 11 12 13 14	This requirement was not met as evidence by: LPA’s observation of a carbon monoxide detector, however it was not plugged in and did not have a battery installed.	8 9 10 11 12 13 14

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: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2019

LIC809 (FAS) - (06/04)

Page: 3 of 3