414004177-4-22-2022-05-CC-CQUO-CDQTJS-20220422144649

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414004177
Report Date: 04/22/2022
Date Signed: 04/22/2022 02:47:52 PM

Document Has Been Signed on 04/22/2022 02:47 PM - 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:	GONZALEZ, STELLA MARIE		FACILITY NUMBER:	414004177
ADMINISTRATOR:	GONZALEZ, STELLA MARIE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(650) 653-1997
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94403
CAPACITY:	14	CENSUS: 11	DATE:	04/22/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:55 AM
MET WITH:	H1, Jaeckelone Ang		TIME COMPLETED:	03:00 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	On April 22, 2022 at approximately 11:55am, Licensing Program Analyst (LPA) Catrina Quimbo conducted an unannounced, annual inspection. LPA met with H1 and explained the purpose of the inspection. Licensee was not present during inspection. Per H1, licensee was at a doctor's appointment. H1 granted LPA entry to the home to conduct annual inspection. Present during inspection included H1, H2 and 11 enrolled children (all preschool age). Facility is operating within capacity and ratio requirements on this date. Both helpers working at facility have fingerprint clearance on file. LPA advised H1 to contact licensee to alert licensee of LPA's presence and inspection. H1 stated she understood. At approximately 12:10pm, LPA inspected day care areas with H1. The facility is licensed for a large family child care home that consists of 2 bedrooms, 1 bathroom, 1 living room, dining area, kitchen, side yard/driveway, backyard and detached garage. The DAY CARE AREAS that are currently being used are the living room, dining area, bathroom and backyard area. The OFF-LIMITS AREAS are bedroom #2, kitchen, side yard/driveway, and detached garage. All off limit areas are made inaccessible to children by child safety gates and/or child proof door knobs. LPA observed home to have appropriate toys and equipment that were in good condition. Facility operates as a Montessori program. Home has adequate temperature and ventilation. All cleaning supplies, poisons and other chemicals were stored inaccessible to children behind child safety locked cabinets or off limit areas. There were no pools, spas or bodies of water on the property. The entire backyard is enclosed with an at least 5ft high fence. Backyard is equipped with appropriate outdoor toys that were in good working condition. Backyard is shared by a separate licensed provider. Per H1, children do not co-mingle with separate licensed provider's enrolled children. (Continue on Page 2...)

SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

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: GONZALEZ, STELLA MARIE	FACILITY NUMBER: 414004177
	VISIT DATE: 04/22/2022

NARRATIVE

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LPA observed a smoke and carbon monoxide detector, fully charged fire extinguisher and a working telephone on site. Per H1, home does not contain any firearms or weapons. LPA reviewed eleven children's records which were complete. Children's files have a record of emergency identification information on file.

LPA asked H1 of licensee's whereabouts during inspection. Per H1, licensee will not be available during LPA's inspection due to the pre-scheduled doctor's appointment.

LPA reviewed H1 and H2's files. H1 had a valid Pediatric First Aid/CPR certificate that is current and will expire 06/2023. H1 also had proof of required immunizations available for review. LPA reviewed H2's file which was incomplete. H2 did not have proof of required immunizations available for review.

Required licensing documents were posted near door entry. LPA observed a blank emergency disaster drill log that was posted with licensing documents. Per H1, facility has not completed emergency disaster drills.

During Inspection:
- H1 was given information regarding annual fees and Lead Poisoning Facts Flyer.
-H1 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.
-H1 was reminded about Mandated Reporter training available on CCLD website. Training must be completed every 2 years by all staff hired. Training can be taken online at www.mandatedreporterca.com.
-H1 was reminded about the Provider Information Notices (PINs) on CCLD website.
-H1 was advised for any additional questions to contact CCLD office, Monday to Friday, 8:00am - 5:00pm, (650) 266-8800 or 1 (844) 538-8766. Website: www.cdss.ca.gov.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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

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SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

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: GONZALEZ, STELLA MARIE	FACILITY NUMBER: 414004177
	VISIT DATE: 04/22/2022

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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.

Facility representative 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 facility representative 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 facility representative 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.

At approximately 2:20pm, LPA attempted to call licensee via cellphone, however, received voicemail. LPA was unable to leave a voicemail as licensee's voicemail inbox was full.

Facility was cited Type B citation for incomplete staff record. Facility was cited Type B citation for no emergency disaster drill record. Please refer to 809D for more information.

A notice of site visit was given and must remain posted for 30 days.

An exit interview conducted and report was reviewed with facility representative, H1.

SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/22/2022 02:47 PM - 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: GONZALEZ, STELLA MARIE	FACILITY NUMBER: 414004177
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1597.622(a)(1)

(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 is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above by having no record of H2's immunizations readily available for LPA's review, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/20/2022
	Plan of Correction
1 2 3 4	H1 stated they will inform licensee to submit proof of H2's required immunizations to LPA no later than 05/20/2022 by 5:00pm.

Type B

Section Cited

CCR

102417(g)(9)(A)

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on obersvation, interview and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/29/2022
	Plan of Correction
1 2 3 4	H1 stated they will inform licensee to submit proof of an emergency disaster drill to LPA no later than 04/29/2022 by 5:00pm.

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: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

LIC809 (FAS) - (06/04)

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