414002143-1-8-2020-05-CC-CINO-BKMSED-20200108124834

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414002143
Report Date: 01/08/2020
Date Signed: 01/08/2020 12:48:38 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:	JIMENEZ, BIRGINIA		FACILITY NUMBER:	414002143
ADMINISTRATOR:	JIMENEZ, BIRGINIA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(650) 473-9598
CITY:	EAST PALO ALTO	STATE: CA	ZIP CODE:	94303
CAPACITY:	14	CENSUS: 4	DATE:	01/08/2020
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	11:35 AM
MET WITH:	Licensee, Birginia Jimenez		TIME COMPLETED:	01:05 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	Licensing Program Analyst (LPA), Cindy Interiano, met with Licensee, Birginia Jimenez for an Annual/Random inspection. Purpose of the inspection was explained. Present in the facility is Licensee caring for 4 children (3 infants and 1 PreK). Licensee owns home and lives with Husband, Sister, and 4 minor children. Home is a 4 bedroom, 3 bathroom, single level house. Facility was inspected and the Daycare areas are: Living room, Dining area, Bathroom #1, and portions of the front yard. Off limit areas are: Kitchen, Bedrooms #1-4, Bathrooms #2-3, Backyard, Side yards, and portions of the Front yard. All off limit areas, including closets 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. Chimney in the living room is properly barricaded. Home has no bodies of water. There are no poisons, detergents, or cleaning products accessible to daycare children. Licensee states there are guns/weapons in the home, which are properly secured in a locked safe. Weapons are maintained separate from the ammunition. Licensee’s CPR expires at the end of 01/2020, however Licensee has a scheduled training for 01/19/2020. Licensee conducted last emergency drill on 10/11/19 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, as well as Mandated Reporter training certificate. Children’s files were reviewed and are complete and up-to-date. 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: 01/08/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2020

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: JIMENEZ, BIRGINIA	FACILITY NUMBER: 414002143
	VISIT DATE: 01/08/2020

NARRATIVE

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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 Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2020

LIC809 (FAS) - (06/04)

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