414004177-11-28-2023-05-CC-JTSE-CXZUVY-20231128145554

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414004177
Report Date: 11/28/2023
Date Signed: 11/28/2023 02:56:14 PM

Document Has Been Signed on 11/28/2023 02:56 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
SAN BRUNO CC RO, 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: 6	DATE:	11/28/2023
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME BEGAN:	11:35 AM
MET WITH:	H1, Jeckelone Ang		TIME COMPLETED:	03:10 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 11/28/2023, at approximately 11:35AM, Licensing Program Analyst (LPA) Jonathan Tse conducted an unannounced annual visit. LPA was granted entry to the facility by Helper Jeckelone Ang (H1). LPA explained the purpose of the visit. Present in the facility were H1, another helper (H2), one infant, and five preschool age children. Facility is in compliance with capacity ratios this day. All adults present in the home have fingerprint clearance and are associated to the facility. Licensee was not present in the facility. LPA contacted Licensee and they are currently away due to a family emergency. The home is a one-story, two-bedroom, one-bathroom home. Daycare Areas: Living Room, Dining Room, Bathroom and Backyard. Off-limits Areas: Kitchen, Bedroom 1, Bedroom 2. LPA inspected the daycare areas for any health and safety hazards. LPA observed the Living Room and Dining Room to be equipped with age-appropriate toys and learning materials. All electrical outlets are covered with childproof covers or otherwise obstructed by furniture to be inaccessible to children. There is a fireplace present in the Living Room that is covered by furniture and is inaccessible to children. The home is equipped with a fully charged 3A40BC fire extinguisher. LPA observed a carbon monoxide detector and a smoke detector in the hallway to be present in the home. Off-limits areas are secured by childproof gates and childproof doorknobs. There is a first aid kit in the home that needs to be restocked with bandages. The facility provides cots for children to nap in. Sheets are brought from home and are brought back home once a week to be washed. Per H1, there are no firearms present in the facility. The backyard is shared with a separate licensed provider. Per H1, children to do not intermingle. The facility does not use the backyard at the same time as the other licensed provider. LPA observed there to be age-appropriate toys and equipment for children to use in the backyard. All equipment is kept in good repair. There is a play structure that is padded with foam mats and artificial turf, which is sufficient cushioning for children. The backyard is enclosed by a fence that is at least five feet high. Continued on Page Two

SUPERVISOR'S NAME: Ali Zebila	TELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Jonathan Tse	TELEPHONE: (650) 464-4927
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023

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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Document Has Been Signed on 11/28/2023 02:56 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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: GONZALEZ, STELLA MARIE	FACILITY NUMBER: 414004177
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(a)

Operation of A Family Child Care Home

(a) The licensee shall be present in the home and shall ensure that children in care are supervised at all times. When circumstances require the licensee to be temporarily absent from the home, the licensee shall arrange for a substitute adult to care for and supervise the children during his/her absence. Temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/05/2023
	Plan of Correction
1 2 3 4	Licensee shall designate staff to provide care and supervision for children in Licensee's absence. Licensee shall send the written statement to LPA by 12/5/2023.

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 one out of two staff files which poses/ a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/05/2023
	Plan of Correction
1 2 3 4	Staff shall complete Mandated Reporter Training and submit proof of completion to LPA by due date of 12/5/2023.

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: Ali Zebila	TELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Jonathan Tse	TELEPHONE: (650) 464-4927
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/28/2023 02:56 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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: GONZALEZ, STELLA MARIE	FACILITY NUMBER: 414004177
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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 two out of two staff records which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/05/2023
	Plan of Correction
1 2 3 4	Staff shall complete First Aid/CPR training from an EMSA certified vendor and submit proof of completion of training to LPA by due date of 12/5/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Ali Zebila	TELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Jonathan Tse	TELEPHONE: (650) 464-4927
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023

LIC809 (FAS) - (06/04)

Page: 3 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: GONZALEZ, STELLA MARIE	FACILITY NUMBER: 414004177
	VISIT DATE: 11/28/2023

NARRATIVE

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LPA reviewed two staff files and six children’s files. Staff files included LIC9108, immunization records, and signed Notification of Employee Rights. H1 does not have complete First Aid/CPR certification and has only completed the online portion of the training. H1’s Mandated Reporter Training is current and expires 12/2024. All children’s files were observed to be complete and included immunization records, Identification and Emergency Information, and Notification of Parents’ Rights.

The facility last conducted an emergency drill on 10/18/2023. Emergency drills are properly logged and documented. The facility prepares morning snack, lunch, and afternoon snack for children in care.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

H1 was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with H1 and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/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.

Continued on Page Three

SUPERVISOR'S NAME: Ali Zebila	TELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Jonathan Tse	TELEPHONE: (650) 464-4927
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: GONZALEZ, STELLA MARIE	FACILITY NUMBER: 414004177
	VISIT DATE: 11/28/2023

NARRATIVE

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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.

H1 was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, H1 confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

See LIC809-D for deficiencies cited today.

A notice of site visit was given and must remain posted for 30 days. Appeal rights were provided.

Exit interview conducted and report was reviewed with H1. Report will be emailed to Licensee, Stella Gonzalez.

SUPERVISOR'S NAME: Ali Zebila	TELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Jonathan Tse	TELEPHONE: (650) 464-4927
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023

LIC809 (FAS) - (06/04)

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