414004443-1-13-2020-05-CC-CINO-BKNSL7-20200109125751

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414004443
Report Date: 01/09/2020
Date Signed: 01/13/2020 01:22:46 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:	GONZALEZ, ADOLFINA		FACILITY NUMBER:	414004443
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 5	DATE:	01/09/2020
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Licensee, Adolfina Gonzalez		TIME COMPLETED:	01:15 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	Licensing Program Analyst (LPA), Cindy Interiano, met with Licensee, Adolfina Gonzalez for an Annual/Random inspection. Purpose of the inspection was explained. Present in the facility is Licensee caring for 5 children (2 Infants and 3 PreK). Licensee owns home and lives with her 3 Adult children. Home is a 5 bedroom, 3 bathroom, two level house. Facility was inspected and the Daycare areas are: Lower level: Living room, Dining area, Family Room, Bathroom #1, Front yard, and portion of the Back yard. Off limit areas are: Garage, Kitchen, Bedroom #1, portion of Backyard, Storage in the backyard, Side yards, and entire 2ndfloor: Bedrooms #2-5, Bathroom #2 and #3. All off limit areas, including closets, are properly barricaded. LPA observed the following: Daycare area is equipped with age appropriate toys and equipment for the children. Home has sufficient lighting and ventilation. Home has a working telephone, a working smoke and carbon monoxide detector, and a fully charged fire extinguisher. Home has no Chimney or bodies of water. There are no poisons, detergents, or cleaning products accessible to daycare children. Licensee states there are no guns/weapons in the home. Licensee’s CPR has since expired. Licensee conducted last emergency drill on 11/25/19 and is properly logged. Licensee provides daily snacks and meals. Discipline policy is mainly redirection. All required postings are properly posted. Licensee has required proof of immunization on file. Backyard is currently not being used because toys/equipment got wet due to the recent rains. Licensee is in the process of ‘drying out’ the backyard and may be installing a new terrace/roof. See Page 2. . .

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2020

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: GONZALEZ, ADOLFINA	FACILITY NUMBER: 414004443
	VISIT DATE: 01/09/2020

NARRATIVE

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Page 2. . .

During inspection,
*Incidental Medical Services (IMS) policy was discussed.
*Licensee was reminded about having all Staff and Volunteers provide proof of immunization against influenza, pertussis, and measles or qualifies for an exemption.
*Licensee was reminded about the Provider Information Notices (PINs) on CCLD website.
*Licensee was reminded about Mandated Reporter Training available on CCLD website
(www.ccld.ca.gov or www.mandatedreporterca.com). Licensee will take training once it is available in Spanish.
*Licensee was advised of the new Lead Bill (effective 01/01/19), requiring Facilities to distribute a two-page flyer to Guardians with information on lead poisoning facts.
*Licensee was given information regarding ‘Safe Sleep’ practices.

>See attached page for deficiencies issued today under Title 22 Division 12 of the Ca. Code of Regulations.

>This report and rights to comment and appeal were discussed with Licensee. This report must be available in the facility for public review. Notice of site visit was observed being posted.
Licensee was advised any additional questions to call Office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website: www.cdss.ca.gov

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2020

LIC809 (FAS) - (06/04)

Page: 2 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: GONZALEZ, ADOLFINA	FACILITY NUMBER: 414004443
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/09/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/24/2020 Section Cited	1 2 3 4 5 6 7	102416(c) Personnel Requirements - The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid
	8 9 10 11 12 13 14	pursuant to Health and Safety Code Section 1596.866. This requirement was not met as evidenced by: Licensee does not having current CPR training. This is a potential health and safety risk to children in care.	8 9 10 11 12 13 14
Type B 01/24/2020 Section Cited	1 2 3 4 5 6 7	102417(b) Operation of a Family Child Care Home - The home shall be kept clean and orderly, with heating and ventilation for safety and comfort. This requirement was not met as
	8 9 10 11 12 13 14	evidence by: Home was not orderly due to Licensee organizing her closets and Garage, causing potential tripping hazards and blocking walk paths. This is a potential health and safety risk to children in care.	8 9 10 11 12 13 14

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: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2020

LIC809 (FAS) - (06/04)

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