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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414001409
Report Date: 05/09/2022
Date Signed: 05/09/2022 04:32:23 PM


Document Has Been Signed on 05/09/2022 04:32 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:DIAZ, MARIA BETTINA C.FACILITY NUMBER:
414001409
ADMINISTRATOR:DIAZ, MARIA BETTINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 579-2678
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY:14CENSUS: 5DATE:
05/09/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Maria Bettina DiazTIME COMPLETED:
04:40 PM
NARRATIVE
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On 5/9/2022 at 1:45P.M. Licensing Program Analyst (LPA) Luis J. Gomez conducted an unannounced complaint investigation and met with licensee, Maria Bettina Diaz. Purpose of inspection was explained and was a Case Management report to cite deficiencies observed during the complaint inspection. LPA inspected facility with licensee for health and safety hazards.

At 2:30P.M., Based on record review and interview, LPA confirmed licensee does not have Individual Infant Sleep Plan for qualifying infant in care. During inspection, Advisory Note: Technical Assistance (LIC9102) was issued.

At 2:45P.M, Based on record review and interview, LPA confirmed licensee is not maintained required infant napping logs, with documentation of each 15 minute check.

Based on today’s inspection, deficiencies were observed in areas evacuated according the Title 22 Division 12 of Ca. Code of Regulations and cited on the 809D. An exit interview and plan of correction was discussed with the Licensee, Maria Bettina Diaz and signature of this form acknowledges the receipt of these documents.



A copy of this report and appeal rights were reviewed and provided to the licensee. Notice of site visit was posted and shall remain posted for 30 days.
SUPERVISOR'S NAME: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2022
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 05/09/2022 04:32 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: DIAZ, MARIA BETTINA C.
FACILITY NUMBER: 414001409

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/13/2022
Section Cited

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102425(j)(2)(D) Infant Safe Sleep: Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Date, infant’s name and time of each 15-minute check. This requirement was not met as evidenced by:
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Based on record review and interview, LPA confirmed licensee is not maintained required infant napping logs, with documentation of each 15 minute check. This poses a potential health and safety risk to children in care.
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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: 05/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2022
LIC809 (FAS) - (06/04)
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