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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004158
Report Date: 10/12/2021
Date Signed: 10/12/2021 12:19:22 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:ESPINOZA, VICTORIAFACILITY NUMBER:
414004158
ADMINISTRATOR:ESPINOZA, VICTORIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 520-9802
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY:14CENSUS: 7DATE:
10/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Victoria EspinozaTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Marie Rodriguez conducted an unannounced Annual Inspection. LPA met with Licensee Victoria Espinoza and explained purpose of inspection. Present in home were the Licensee, Licensee's husband, Licensee's two minor children, a helper, and five children (two infants and three preschool aged). Home is operating within ratio and capacity requirements on this day. All adults working in the home have a criminal record clearance. Hours of operation are Monday to Friday from 7:00am to 6:00pm.

Day Care Areas: Living Room, kitchen, dining area, bedroom #2 (toddler nap room), bedroom #3 (infant nap room), bathroom, deck, and backyard. Off Limit Areas: Master bedroom, garage, porch, and loft above garage. LPA inspected day care areas of home with Licensee. LPA observed the home to be clean and in good repair with proper temperature and ventilation. There are no bodies of water on the property. The fireplace is properly barricaded. There is a variety of age appropriate toys and equipment in the home. The deck and backyard are clean and have age appropriate toys and outdoor equipment which are in good condition. The deck has a secured gate leading to the backyard. The play structure in the backyard is in good condition and has cushioning underneath. All cleaning supplies, poisons, and other chemicals are stored inaccessible to children. There is a working smoke and carbon monoxide detector, a fully charged fire extinguisher, and a working telephone available.

Five children records reviewed were complete. All children have a record of emergency identification information on file. Licensee's Pediatric First Aid/CPR certificate expires October 2022. Two staff records reviewed were complete. Last emergency drill was conducted in July 2021. Emergency drills are conducted every six months and are properly logged.

No deficiencies cited today under California Code of Regulations, Title 22, Division 12.

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

DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021
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 3
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: ESPINOZA, VICTORIA
FACILITY NUMBER: 414004158
VISIT DATE: 10/12/2021
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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.

Exit interview conducted and report was reviewed with Licensee Victoria Espinoza.
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Marie RodriguezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3