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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414002587
Report Date: 02/12/2020
Date Signed: 02/12/2020 03:08:07 PM

COMPREHENSIVE INSPECTION
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:NETANE, PAULINE H.FACILITY NUMBER:
414002587
ADMINISTRATOR:NETANE, PAULINE H.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 430-7536
CITY:BELMONTSTATE: CAZIP CODE:
94002
CAPACITY:14CENSUS: 9DATE:
02/12/2020
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Pauline NetaneTIME COMPLETED:
03:27 PM
NARRATIVE
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On February 12, 2020 at 11:30 a.m., Licensing Program Analyst (LPA) April Cowan conducted an unannounced Annual Inspection and met with Licensee. LPA disclosed the purpose of the inspection and was granted entry into the facility by the Licensee. Present in the facility is Licensee caring for 4 children (1 infants and 3 preschoolers). At 12:35 PM, five school-aged children arrived. Licensee owns home, which is a 3 bedroom, 1 bathroom, split level house. Facility was inspected and Daycare areas are: living room, dining room, bedroom 1 and 2, bathroom 1, and backyard. Off Limit areas are: Bedroom 3 and garage.
LPA observed the following: Daycare area is clean, 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. There are no bodies of water in the Home. There are no poisons, detergents, or cleaning products accessible to day-care children. Licensee states there are no guns or weapons of any kind in the home. Licensee conducted last emergency drill on 10/9/19 and is properly logged. Licensee provides daily snacks and meals. Discipline policy is time out. Licensee states that she will have children sit for one minute to cool off. All required postings are properly posted. Licensee has required proof of immunization and Mandated Reporter Training certificate on file.
>>> See next page
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: April CowanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2020
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 4
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: NETANE, PAULINE H.
FACILITY NUMBER: 414002587
VISIT DATE: 02/12/2020
NARRATIVE
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At 12:20, Licensee stated that hired helper didn't have immunizations nor TB clearance.
At 12:48 LPA reviewed two staff files. LPA observed that licensee's CPR and First-Aid Certification expired on 11-17-19. LPA observed that helper is missing Measles, Pertussis, FLU and TB Clearance. LPA reviewed five children's files. At 1:25 PM, LPA observed that child 5's file is not complete with licensing forms.
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 given information regarding ‘Safe Sleep’ practices.

An exit interview was conducted and plans of Correction were reviewed and developed with the Licensee. A copy of this report and appeal rights were discussed and left with licensee whose signature on this form confirms receipt of these documents.

> See attached page for deficiency cited today.
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: April CowanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2020
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: NETANE, PAULINE H.
FACILITY NUMBER: 414002587
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/12/2020
Section Cited

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1597.622(a)(1)Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. This requirement was not met as evidenced by:
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During today's inspecton LPA observed that licensee did not collect helpers immunizations before working in facility.
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Type B
03/12/2020
Section Cited

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102416(c) Personnel Requirements. The Licensee and other personnel as specified shall complete training on preventive health practices including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.86. This requirement is not met as evidenced by:
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LPA observed through record review that licensee did not renew CPR and First Aid Training.
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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: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: April CowanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2020
LIC809 (FAS) - (06/04)
Page: 4 of 4
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: NETANE, PAULINE H.
FACILITY NUMBER: 414002587
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/12/2020
Section Cited

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102421(a) Child's Records. The licensee shall maintain, in each child’s record, the signed and dated notice form LIC 995A, Parents Rights Notice. This requirement was not met as evidenced by:
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LPA observed that licensee did not have Parents Rights Notice in Child 5 folder.
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Type B
03/12/2020
Section Cited

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102421(b) Childs Records. The licensee shall maintain, in each child’s record, a copy of the emergency information card required in Section 102417(g) (7). This requirement was not met as evidenced by:
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LPA observed that licensee did not collect Emergency Information for Child 5
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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: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: April CowanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2020
LIC809 (FAS) - (06/04)
Page: 3 of 4