414001205-12-14-2023-05-CC-JTSE-CYJ345-20231214165435

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414001205
Report Date: 12/14/2023
Date Signed: 12/14/2023 04:55:01 PM

Document Has Been Signed on 12/14/2023 04:55 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:	WILSON, SANDRA & GONZALES, VERONICO		FACILITY NUMBER:	414001205
ADMINISTRATOR:	SANDRA W. & VERONICO G.		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(650) 573-1565
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94403
CAPACITY:	14	CENSUS: 13	DATE:	12/14/2023
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Licensee, Veronico Gonzales		TIME COMPLETED:	05:00 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 12/14/2023, at approximately 2:30PM, Licensing Program Analyst (LPA) Jonathan Tse conducted an unannounced annual visit at the facility. LPA was granted entry to the facility by co-Licensee, Veronico Gonzalez. LPA explained the purpose of the visit. Present in the facility was the co-Licensee Veronico Gonzalez, two helpers (H1 and H2), one infant, eleven preschool-age children, and one school-age child. The facility is within capacity requirements on this day. All adults working or living in the home have fingerprint clearance and are associated to the facility. The facility’s operating hours are from 8:00AM to 5:30PM, Monday to Friday. The facility is a three-bedroom, two-bathroom home. Daycare Areas: Living Room, Kitchen, Master Bedroom, Bathroom #1, Bathroom #2 (attached to Master Bedroom), Backyard and Garage (converted into classroom). Off-limits Areas: Bedroom #2 and Bedroom #3. LPA and co-Licensee inspected the home for any health and safety hazards. LPA observed the home to be in orderly condition. There are age-appropriate toys and learning materials present in the Living Room and Garage. The home is equipped with a fully charged 3A40BC fire extinguisher. There are smoke and carbon monoxide detectors present in the home. Co-Licensee demonstrated that at least one of the detectors was operational. There is a fire alarm system running throughout the home. There are emergency exit route maps posted throughout the home. LPA reminded co-Licensee to regularly test the detectors to ensure that they are all operational. There is a fireplace present in the Living Room that is blocked with furniture to be inaccessible to children. LPA discussed maintaining the first aid kit present in the home by ensuring that it is stocked as much as possible with bandages and gauze. Per co-Licensee, there are no firearms present in the home. Continued on Page Two

SUPERVISOR'S NAME: Ali Zebila	TELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Jonathan Tse	TELEPHONE: (650) 464-4927
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

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 12/14/2023 04:55 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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: WILSON, SANDRA & GONZALES, VERONICO	FACILITY NUMBER: 414001205
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/14/2023

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 record review, the licensee did not comply with the section cited above in two out of three personnel files which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/10/2024
	Plan of Correction
1 2 3 4	Licensee shall have all adults who are currently working in the home complete Mandated Reporter Training and submit proof of completion to LPA by set due date of 12/22/2023.

Type B

Section Cited

CCR

102416(c)

Personnel Requirements

(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in two out of three personnel files which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/12/2024
	Plan of Correction
1 2 3 4	Licensee shall have all adults complete First Aid/CPR training from a vendor that is EMSA-certified. Licensee can also have training completed via the American Red Cross or the American Heart Association. Licensee shall submit proof of completion by set due date of 12/29/2023.

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: Ali Zebila	TELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Jonathan Tse	TELEPHONE: (650) 464-4927
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC809 (FAS) - (06/04)

Page: 2 of 8

Document Has Been Signed on 12/14/2023 04:55 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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: WILSON, SANDRA & GONZALES, VERONICO	FACILITY NUMBER: 414001205
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102419(d)(1)

Admission Procedures and Authorized Representatives Rights

(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or authorized representative has received and read the LIC 995A. The bottom portion of this form must be kept in the child’s file as proof that the parent or authorized representative has been notified of his or her rights and received a copy of the Caregiver background Check Process, LIC 995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in ten out of thirteen children's files which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/10/2024
	Plan of Correction
1 2 3 4	Licensee shall have all parents read and sign LIC995A and maintain the signed copy in the children's files by set due date of 12/29/2023.

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: Ali Zebila	TELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Jonathan Tse	TELEPHONE: (650) 464-4927
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC809 (FAS) - (06/04)

Page: 3 of 8

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: WILSON, SANDRA & GONZALES, VERONICO	FACILITY NUMBER: 414001205
	VISIT DATE: 12/14/2023

NARRATIVE

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The Backyard was observed to be in orderly condition. Toys and equipment were observed to be in good repair. There is sufficient cushioning for children in the form of padded mats. The Backyard is enclosed by a fence that is at least five feet high.

LPA reviewed three personnel files and thirteen children’s files. There are no staff with EMSA-certified CPR/First Aid training present during the visit today. LPA discussed the requirement to acquire training that is EMSA-certified. Co-Licensee’s Mandated Reporter Training expired on 4/2021.

Children’s files all included Emergency and Identification Information (LIC700) and Parents’ Notification of Additional Children in Care (LIC9150). During record review, LPA observed that ten out of thirteen files did not have a signed copy of the Notification of Parents’ Rights (LIC995A). LPA discussed the difference between PUB394 and LIC995A with co-Licensee.

LPA observed all required postings to be publicly accessible on the main entrance of the facility. Additional copies of the postings are also available for review in the Garage. Per co-Licensee, emergency drills are conducted every month. Emergency drill logs are not current. The facility prepares breakfast, lunch, and AM/PM snack for children in care.

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 CARE tools, please send email inquiries 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/inforesources/community-care-licensing/inspection-process.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record 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.

Continued on Page Three

SUPERVISOR'S NAME: Ali Zebila	TELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Jonathan Tse	TELEPHONE: (650) 464-4927
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC809 (FAS) - (06/04)

Page: 7 of 8

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: WILSON, SANDRA & GONZALES, VERONICO	FACILITY NUMBER: 414001205
	VISIT DATE: 12/14/2023

NARRATIVE

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LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, a Plan for Providing 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) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the
ADA, available at: https://www.ada.gov/resources/child-care-centers/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, co-Licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

See LIC809-D for deficiencies cited today. Appeal rights were printed and given to co-Licensee.
A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the co-Licensee, Veronico Gonzalez.

SUPERVISOR'S NAME: Ali Zebila	TELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Jonathan Tse	TELEPHONE: (650) 464-4927
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC809 (FAS) - (06/04)

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