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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004409
Report Date: 08/03/2023
Date Signed: 08/03/2023 12:55:06 PM


Document Has Been Signed on 08/03/2023 12:55 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:HERNANDEZ, DEBORAFACILITY NUMBER:
414004409
ADMINISTRATOR:HERNANDEZ, DEBORAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 535-9811
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY:14CENSUS: 10DATE:
08/03/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Debora HernandezTIME COMPLETED:
01:00 PM
NARRATIVE
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On 8/3/2023 at 11:40AM., Licensing Program Analyst (LPA), Luis J. Gomez met with licensee, Debora Hernandez. Purpose of inspection was explained and is for an unannounced, plan of correction inspection. Present is licensee, one assistant caring for 10 children. Staff present have criminal record clearances on file. LPA inspected the facility with licensee for health and safety hazards.

During inspection, LPA performed facility record review, observations and interviews,

At 12:00PM., Based on observations, interview and record review, LPA confirmed facility operating beyond the capacity limit stated on the license with six infant- age children in care.

At 12:05PM., Based on observations, LPA confirmed two (2) used diapers in playroom, accessible to the day-care children.

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. Exit interview, evaluation report, and plans for correction was discussed Debora Hernandez and licensees' 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.

Notice of site visit was provided during inspection.
SUPERVISOR'S NAME: Marie RodriguezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2023
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 08/03/2023 12:55 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: HERNANDEZ, DEBORA
FACILITY NUMBER: 414004409

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/04/2023
Section Cited
CCR
102416.5(a)

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102416(a) Staffing Ratio and Capacity. 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:
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Licensee will reduced infant enrollment to the required capacity limit of 4, by the due date: 8/4/2023.

Updated children's roster and schedule, will be submitted to the department.
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At 12:00PM., Based on observations, interview and record review, LPA confirmed facility operating beyond the capacity limit stated on the license with six infant-age children in care. This poses an immediate health and safety risk to children in care.
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Conference will be scheduled at the San Bruno Childcare Regional Office at a later date.
Type A
08/04/2023
Section Cited
CCR102417(g)

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102417(g) Operations of a family child care home. The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not be limited to:
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Licensee will ensure all hazerdous items are removed from on-limit areas at all times. Used diapers were removed from play room during inspection.
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At 12:05PM., Based on observations, LPA confirmed two (2) used diapers in playroom, accessible to the day-care children. This poses an immediate health and safety risk to children in care.
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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: Marie RodriguezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2