<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414002425
Report Date: 12/10/2019
Date Signed: 12/10/2019 01:36:07 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:JACOBO, MARISELA A.FACILITY NUMBER:
414002425
ADMINISTRATOR:JACOBO, MARISELA A.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 440-1245
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY:14CENSUS: 9DATE:
12/10/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Marisela JacoboTIME COMPLETED:
01:50 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 Random inspection. LPA met with Licensee Marisela Jacobo and explained purpose of inspection. Home is a single story house with three bedrooms and two bathrooms. Licensee lives in home with her husband, mother, sister, and four children. Present in home was the Licensee, two of the Licensee's children (not included in ratio), a helper, and 8 children (2 infants and 6 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 5:40pm.

Day Care Areas: Living room, dining room, kitchen, family room, bathroom #1, and backyard. Off Limit Areas: Bedroom #1, bedroom #2, bedroom #3, bathroom #2, and garage. 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, there are no weapons or firearms in the home. There is a variety of age appropriate toys and equipment in the home and outside in the outdoor play area of the backyard which are in good condition. Outdoor play area is fenced for supervision. Napping equipment is in good condition and properly stored. 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 license is current.

Eight children records reviewed were complete. All children have a record of emergency identification information on file. Licensee's record was reviewed and complete. Licensee's Pediatric First Aid/CPR certificate expires February 2021. All Last emergency drill was conducted on December 6, 2019. Emergency drills are conducted at least once a month and are properly logged.

(Continued on second page)
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Marie RodriguezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2019
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 2
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: JACOBO, MARISELA A.
FACILITY NUMBER: 414002425
VISIT DATE: 12/10/2019
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
26
27
28
29
30
31
32
(Continued from first page)

Incidental Medical Services (IMS) was discussed. Licensee has no children who need services at this time. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding Americans with Disabilities Act (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: www.ada.gov/childqanda.htm.

During inspection,
  • Licensee was given information regarding Safe Sleep Practices, Technical Support Program, and a flyer regarding lead testing.
  • Licensee was reminded, as of September 1, 2016, all Staff and Volunteers must provide proof of immunization against pertussis, measles, and influenza, or qualifies for an exemption, pursuant to Health and Safety code 1596.7995 and 1597.622.
  • Licensee was reminded about Mandated Reporter training available on CCLD website. Training must be completed every 2 years. Training can be taken online at www.mandatedreporterca.com
  • Licensee was reminded about the Provider Information Notices (PINs) on CCLD website.
  • Licensee was advised for any additional questions to contact CCLD office, Monday to Friday, 8:00 am - 5:00 pm, (650) 266-8800 or 1 (844) 538-8766. Website: www.cdss.ca.gov.

No deficiencies cited today.

This report was reviewed and discussed with Licensee Galina Galant. A copy of report was provided.
Notice of site visit was observed being posted and shall remain posted for 30 days.
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Marie RodriguezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2019
LIC809 (FAS) - (06/04)
Page: 2 of 2