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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004409
Report Date: 06/14/2023
Date Signed: 06/14/2023 01:40:20 PM


Document Has Been Signed on 06/14/2023 01:40 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 CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:HERNANDEZ, DEBORAFACILITY NUMBER:
414004409
ADMINISTRATOR:HERNANDEZ, DEBORAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 535-9811
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY:14CENSUS: 13DATE:
06/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Maritess Abendano, Debora HernandezTIME COMPLETED:
01:45 PM
NARRATIVE
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On 6/14/2023 at 8:55AM., Licensing Program Analysts (LPA), Luis J. Gomez met with Licensee, Debora Hernandez and Licensee's Daughter, Maritess Abendano. Purpose of the inspection was explained and was for an Unannounced, Annual Random inspection. Present in facility was the licensee, licensee’s daughter and two helpers caring for 9 children. During inspection, 3 additional children arrived. (6 Infant Age, 1 School Age, 6 Preschool Age). Per licensee, two children present are her grand children. Licensee’s home is a four bedroom, two bathroom, one level house. Days and Hours of operations are: Monday – Friday, 8:00AM., to 5:00PM. Day-care Areas: Living Room, Bedroom #1, Bathroom #1, and Backyard Area #1. Off-limit Area: Bedrooms #2, #3, #4, Bathroom #2, Kitchen, Garage Area, Backyard Areas #2, #3. LPA inspected facility with licensee, for health and safety hazards.

At 9:00AM., the following was observed: Facility has age-appropriate playthings available for the children. Floors and ground surfaces were clear of obstructions.

At 9:05AM., Based on observations, LPA confirmed exposed bricks in facility playroom, accessible to children in care.

At 9:35AM., Based on observations, LPA confirmed two infant- age children, awake in napping cribs for several minutes.

Accessible furniture, toys and books inspected were in good repair. For napping services, LPA observed several cots and playpens stored in playroom and bedroom #1. Per licensee, napping sheets are washed weekly. Off-limit area have been made inaccessible to children. Bathroom #1 was maintained clean, with adequate supplies for hand washing. Fixtures were in operating condition. Facility was the proper temperature, with ventilation, and lighting. Home had functioning telephone service, smoke detector, carbon monoxide detector, and fully changed fire extinguisher (2A10BC).

At 9:35PM., LPA inspected backyard area. Area is completely enclosed with tall fencing and was free of debris or hazardous plants. Home does not have any pools, fishponds, jacuzzi, or bodies of water. (REFER TO 809C, FOR CONT)
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023
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 06/14/2023 01:40 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 CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: HERNANDEZ, DEBORA
FACILITY NUMBER: 414004409

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to:

This requirement is not met as evidenced by:
Deficient Practice Statement
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At 9:05AM., Based on observations, LPA confirmed exposed bricks in facility playroom, accessible to children in care. This poses a potential health and safety risk to children in care.
POC Due Date: 06/16/2023
Plan of Correction
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Licensee will ensure brick is covered and/ or made inaccessible by the due date: 06/16/2023. Proof of correction will be submitted to the department via email.
Type B
Section Cited
CCR
102425(e)
Infant Safe Sleep
No infant shall be forced to sleep, to stay awake, or to stay in the designated sleeping area.

This requirement is not met as evidenced by:
Deficient Practice Statement
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At 9:35AM., Based on observations, LPA confirmed two infant- age children, awake in napping crib for several minutes. This poses a potential health and safety rick to children in care.
POC Due Date: 06/16/2023
Plan of Correction
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Licensee will review and implement safe sleep requirements stated on pin (20-24-CCP) by the due date: 6/16/2023. Proof of correction will be submitted to the department via email.
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 ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/14/2023 01:40 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 CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: HERNANDEZ, DEBORA
FACILITY NUMBER: 414004409

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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At 11:30AM., Based on record review, LPA confirmed required 'Individual Infant Sleeping Plan', LIC9227, missing for qualifying infant in care. This poses a potential health and safety risk to children in care.
POC Due Date: 06/16/2023
Plan of Correction
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Licensee will ensure families signed the required, LIC9227, Individual Infant Sleeping Plan, by the due date: 6/16/2023. Proof of correction will be submitted go the department via email.
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check

This requirement is not met as evidenced by:
Deficient Practice Statement
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At 10:50AM., Based on record review, LPA confirmed facility not documenting infant napping conditions every 15 minutes. This poses a potential health and safety risk to children in care.
POC Due Date: 06/16/2023
Plan of Correction
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Licensee will document and maintain, infant napping conditions for each 15 minutes by the due date: 6/16/2023. Proof of correction will be submitted to the department via email.
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 ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023
LIC809 (FAS) - (06/04)
Page: 3 of 10


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: HERNANDEZ, DEBORA
FACILITY NUMBER: 414004409
VISIT DATE: 06/14/2023
NARRATIVE
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(Page 2)
At 9:45AM, LPA reviewed facility and children’s records.

LPA reminded licensee to complete required ‘Mandated Reporter Certification’ (AB1207), and maintain proof of staff's required immunization. Advisory Note: Technical Violations (LIC9102TV) were issued.

At 9:50AM., Based on record review, observations and interviews, LPA confirmed staff member, S5, present without criminal record clearance on file.

Children’s files were reviewed and included the: Identification of Emergency Information (LIC700); Notification of Parent's Rights (LIC995); and Consent for Medical Treatment (LIC627).

At 10:20AM., Based on observations, interviews, record review, LPA confirmed facility operating beyond the capacity limit stated on the license with six infants in care.

At 10:50AM., Based on record review, LPA confirmed facility not documenting infant napping conditions every 15 minutes.

At 11:30AM., Based on record review, LPA confirmed required 'Individual Infant Sleeping Plan', LIC9227, missing for qualifying infant in care.

LPA reminded licensee to ensure children's immunization records are stored facility. Advisory Note: Technical Violation (LIC9102TV) was issued.

LPA reminded licensee to renew CPR/1st Aid Certification every two years. Advisory Note: Technical Violation (LIC9102TV) was issued.



Licensee reminded licensee to conducted required emergency conducted disaster drill every two years. Licensee stated she would conduct drill within the week.

Required posting are posted, including Childcare License, Notification of Parent’s Rights (PUB379), Emergency Disaster Plan (LIC610A). Per licensee, isolation of an ill children is in the playroom.

LPA advised licensee to ensure all children’s meal containers brought by families must be labeled. Per licensee, home does not have any firearms.

(REFER TO 809C, FOR CONT.)

SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
LIC809 (FAS) - (06/04)
Page: 6 of 10
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: HERNANDEZ, DEBORA
FACILITY NUMBER: 414004409
VISIT DATE: 06/14/2023
NARRATIVE
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(Page 3)
LPA discussed the safe sleep regulations with licensee and discussed Child Care Licensing Safe Sleep Web page at:https://www.cdss.ca.gov/inforesource/child-care-licesning/public-information-and-resources/safe-sleep as an additional resource. LPA informed licensee of the importance of checking for recalled infant devices on United States consumer Product Safety Commission (CPSC) website at http://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

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 tool, please send them 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/inforesource/community-care-licensing/inspection-process.

Based on today's inspection, deficiencies were observed in areas evaluated according to California Title 22, Div. 12 Chap. 3 Health and Safety Code of Regulations and cited on 809D. In exit interview, evaluation report, and plans for correction was discussed with Licensee, Debora Hernandez and signature of this form acknowledges receipt of these documents.

Type “A” violations were issued today. Licensee was advised to provide a copy of the Evaluation Report and all Type “A” Deficiencies cited, to parents and guardians of children currently enrolled in care and to parents of newly enrolled children during the next 12 months. A signed and dated LIC 9224 (Deficiency and Acknowledgment of Receipt of Licensing Reports) shall be maintained in all children's files.

A civil penalty of $300.00 was assessed during inspection.

Notice of Site Visit was provided and must remain posted for 30 days.
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
LIC809 (FAS) - (06/04)
Page: 7 of 10
Document Has Been Signed on 06/14/2023 01:40 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 CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: HERNANDEZ, DEBORA
FACILITY NUMBER: 414004409

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102370(d)
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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At 9:50AM., Based on record review, observations and interviews, LPA confirmed staff member, S5, present without criminal record clearance on file. This poses an immediate health and safety risk to children in care.
POC Due Date: 06/15/2023
Plan of Correction
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Licensee will ensure helper, S5, receives criminal record clearance prior to presence in facility. Proof of correction will be submitted to the department via email.
Type A
Section Cited
CCR
102516.5
(a) The capacity specified on the license shall be the maximum number of children for whom care may be provided at any one time.


This requirement is not met as evidenced by:
Deficient Practice Statement
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At 10:20AM., Based on observations, interviews, record review, LPA confirmed facility operating beyond the capacity limit stated on the license with six infants in care. This poses an immediate health and safety risk to children in care.
POC Due Date: 06/15/2023
Plan of Correction
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Licensee will reduced child enrollment to the required capacity limit specified on license by the due date: 6/15/2023. Proof of correction will be submitted to department via emailed
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 ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023
LIC809 (FAS) - (06/04)
Page: 8 of 10