414002587-4-7-2022-05-CC-ACON-CD9NCL-20220407102056

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414002587
Report Date: 04/06/2022
Date Signed: 04/07/2022 10:23:57 AM

Document Has Been Signed on 04/07/2022 10:23 AM - It Cannot Be Edited

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:	BELMONT	STATE: CA	ZIP CODE:	94002
CAPACITY:	14	CENSUS: 2	DATE:	04/06/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Pauline Netane		TIME COMPLETED:	01:35 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	On April 6, 2022 at 9:25 AM, 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 2 children (1 infant and 1 school age). Licensee owns home, which is a 3 bedroom, 1 bathroom, split level house. Facility was inspected and Day-care 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: Day-care 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 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 provides daily snacks and meals. All required postings are properly posted. Licensee has required proof of immunization on file. >>> See next page

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: April Cowan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022

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: NETANE, PAULINE H.	FACILITY NUMBER: 414002587
	VISIT DATE: 04/06/2022

NARRATIVE

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During inspection,
Precautions for the COVID-19 were discussed. Emergency Evacuations were discussed. Record keeping and childcare safety were discussed. LPA discussed discipline with licensee as well.

At 10:29 AM, LPA reviewed facility records. LPA observed that Licensee has not conducted an emergency drill within the last six months. A technical violation is issued today. LPA observed that licensee did not have a current CPR & First Aid or Mandated Reporter Training on file. The above are potential risks for children in care and Type B citations are issued this day. LPA reviewed children’s files.Children's files are complete with all required Licensing documents.

*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‘Safe Sleep’ Regulations.

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 (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: http://www.ada.gov/childqanda.htm
>>> See next page

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: April Cowan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022

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: NETANE, PAULINE H.	FACILITY NUMBER: 414002587
	VISIT DATE: 04/06/2022

NARRATIVE

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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.

Exit interview conducted and report was reviewed with the licensee Pauline Natane.

> See attached page for deficiency cited today.

>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 is to be posted for 30 days.
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

Copy of this report was reviewed and will be emailed to licensee, Pauline Natane at JUBILEE_DAY_CARE@YAHOO.COM by the close of business on 4/6/22. Confirmation of receipt is required. Signed copy of this report will be stored in the facility file.

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: April Cowan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/07/2022 10:24 AM - It Cannot Be Edited

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: 04/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.8662(b)(1)

Administration of Child Day Care Licensing

(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on (record review), the licensee did not comply with the section cited above in licensee did not renew her Mandated Reporter Training which expired 4-25-21 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/18/2022
	Plan of Correction
1 2 3 4	Licensee agrees to email licensee a copy of current Mandated Reporter training by 4-18-22.

Type B

Section Cited

CCR

102416(c)

Personnel Requirements

(c) 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 1596.866. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on (record review) the licensee did not comply with the section cited above in that licensee did not renew her CPR and First Aid Training that expired on 3-10-22 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/06/2022
	Plan of Correction
1 2 3 4	Licensee agrees to email LPA a copy of current CPR and First Aid Certification by 5-6-22.

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 Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: April Cowan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022

LIC809 (FAS) - (06/04)

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