414002425-1-24-2022-05-CC-MROZ-CAYR43-20220124114052

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414002425
Report Date: 01/24/2022
Date Signed: 01/24/2022 11:40:59 AM

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 MATEO	STATE: CA	ZIP CODE:	94401
CAPACITY:	14	CENSUS: 6	DATE:	01/24/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Marisela Jacobo		TIME COMPLETED:	12:00 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	Licensing Program Analyst (LPA) Marie Rodriguez conducted an unannounced Annual 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 were the Licensee, her husband, her sister, two of the Licensee's children (one not included in ratio), a helper, and 5 children (4 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 5:30pm. 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. Licensee has two dogs who are registered and vaccinated. Five children records reviewed were complete. All children have a record of emergency identification information on file. Licensee and helper's records were reviewed and complete. Licensee's Pediatric First Aid/CPR certificate expires May 2023. All Last emergency drill was conducted on January 2022. Emergency drills are conducted at least once a 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: 01/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2022

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: JACOBO, MARISELA A.	FACILITY NUMBER: 414002425
	VISIT DATE: 01/24/2022

NARRATIVE

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Incidental Medical Services (IMS) policy was discussed. 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 ADA was provided: US Department of Justice (US DOJ) 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: http:://www.ada.gov/childqanda.htm.

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 Marisela Jacobo.

SUPERVISOR'S NAME: Daniel J Oquendo	TELEPHONE: (650) 266-6880
LICENSING EVALUATOR NAME: Marie Rodriguez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2022

LIC809 (FAS) - (06/04)

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