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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004443
Report Date: 02/05/2020
Date Signed: 02/05/2020 02:49:42 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, ADOLFINAFACILITY NUMBER:
414004443
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 4DATE:
02/05/2020
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Licensee, Adolfina GonzalezTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA), Cindy Interiano, met with Licensee, Adolfina Gonzalez. Purpose of the inspection was explained and was for a POC (Plan of Corrections) Inspection. Present in the home is Licensee and Adult Daughter caring for 4 children (2 infants and 2 PreK).

Deficiencies issued on 01/09/20 are the following:

>102416(c) Personnel Requirements - Licensee does not having current CPR training.
On 01/17/20, Licensee faxed copy of CPR card expiring on 01/2022. Also included was copy of Licensee's Adult Daughters' CPR cards.

>102417(b) Operation of a Family Child Care Home - Home was not orderly
Home was inspected for Health and Safety hazards. Daycare areas are: Lower level: Living room, Dining area, Family Room, Bathroom #1, Front yard, and portion of the Back yard.
Licensee has since removed all potential tripping hazards and blocking of walking paths in the daycare care. LPA observed Daycare area now being clean, orderly, and equipped with age appropriate toys and equipment for the children.

Deficiencies issued on 01/09/2020 have been cleared.

**No deficiencies were cited against the facility today under CCR,Title 22, Div. 12, Chapt. 1

This report and rights to comment and appeal were discussed with Licensee. This report must be kept in the facility available for public review. Notice of site visit was observed being posted.
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2020
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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