414002143-1-26-2022-05-CC-MROZ-CB2V2H-20220126150312

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414002143
Report Date: 01/26/2022
Date Signed: 01/26/2022 03:03:27 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:	01/26/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Birginia Jimenez		TIME COMPLETED:	03:15 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) Marie Rodriguez conducted an unannounced Annual inspection. LPA met with Licensee Birginia Jimenez and explained purpose of inspection. Home is a 4 bedroom and 3 bathroom single story house. Present in home were the Licensee, her mother, and four children (3 infants and 1 preschool age). Licensee is operating within capacity requirements on this day. All adults living or working in the home have a criminal record clearance on file. Hours of operation are Monday to Friday from 7:00am to 5:00pm. Day Care Areas: 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. LPA toured day care areas of home with Licensee. LPA observed home to be clean and in good repair with proper temperature and ventilation. Per Licensee, firearms are locked in a secured safe in the home. There is a variety of age appropriate toys and equipment in the home which are in good condition. Front yard is fenced for supervision. Front yard has outdoor age appropriate toys and equipment which are in good repair. Play structures have sufficient padding underneath. All cleaning supplies, poisons, and other chemicals are stored inaccessible to children. There is a working smoke detector and carbon monoxide detector, a fully charged fire extinguisher, and a working telephone. Phone number listed for Licensee is current. Four children's records reviewed were complete. All children have a record of emergency identification information on file. Licensee's record was reviewed and complete. Licensee has a current Pediatric First Aid/CPR certificate which expires January 2024. Last emergency drill was conducted on January 2022. Emergency drills are conducted at the beginning of each month and are properly logged. No deficiencies cited today under California Code of Regulations, Title 22, Division 12. (Continued on next page)

SUPERVISOR'S NAME: Daniel J Oquendo	TELEPHONE: (650) 266-6880
LICENSING EVALUATOR NAME: Marie Rodriguez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2022

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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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: 01/26/2022

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To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

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-and-resources/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.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with Licensee Birginia Jimenez.

SUPERVISOR'S NAME: Daniel J Oquendo	TELEPHONE: (650) 266-6880
LICENSING EVALUATOR NAME: Marie Rodriguez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2022

LIC809 (FAS) - (06/04)

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