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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004443
Report Date: 01/07/2022
Date Signed: 01/07/2022 02:08:14 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:GONZALEZ, ADOLFINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 630-2628
CITY:E PALO ALTOSTATE: CAZIP CODE:
94303
CAPACITY:14CENSUS: 6DATE:
01/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Adolfina GonzalezTIME COMPLETED:
12:00 PM
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On January 7th, 2022 at 9:05am, Licensing Program Analyst (LPA) Tapia-Mandujano conducted an unannounced Annual Required inspection. LPA met with Licensee, Adolfina Gonzalez and explained purpose of inspection. Present in the home were Licensee, licensees' husband, and licensee's two adult children. Licensee is caring for 6 enrolled children (three infants and three preschool age). All adults living and working in the home have a criminal record clearance on file.
Licensee owns home and lives with her 3 Adult children. Home is a 5 bedroom, 3 bathroom, two level house. The Hours of operation are Monday-Friday and open 24 hours. 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 2nd floor: Bedrooms #2-5, Bathroom #2 and #3. All off limit areas, including closets, are properly barricaded.

LPA toured day care areas of home with Licensee. LPA observed home to be in good repair with proper temperature and ventilation. There were a variety of age appropriate toys and equipment in the home which were in good condition. There were no pools, spas or bodies of water on the property. All cleaning supplies, poisons and other chemicals were stored inaccessible to children.

There was a fully charged fire extinguisher, smoke alarm and carbon monoxide alarm, and a working telephone on site. Phone number listed for Licensee is current. Per Licensee, there are no weapons or firearms in the home. LPA reviewed children’s records. LPA also reviewed licensee's records. Licensees CPR & First Aid Certificate expires on 01/2024. Last emergency drill was conducted 12/20/2021. Emergency drills are conducted at least once every six months and are properly logged and posted with important documents.

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SUPERVISOR'S NAME: Cindy InterianoTELEPHONE: (650) 266-8864
LICENSING EVALUATOR NAME: Leslit Tapia-MandujanoTELEPHONE: (650) 350-2554
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2022
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 8
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: 01/07/2022
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Incidental Medical Services (IMS) policy was discussed. Licensee does offer IMS at this time. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: www.ada.gov/childqanda.htm.

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 tools, please send them by email 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.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

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

No deficiencies were cited today under CCR, Title 22, Div. 12, Chapt. 1.

A notice of site visit will be emailed and must remain posted for 30 days.

An exit interview conducted and report was reviewed with the licensee, Adolfina Gonzalez.
SUPERVISOR'S NAME: Cindy InterianoTELEPHONE: (650) 266-8864
LICENSING EVALUATOR NAME: Leslit Tapia-MandujanoTELEPHONE: (650) 350-2554
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2022
LIC809 (FAS) - (06/04)
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