414004443-12-13-2022-05-CC-LTMO-CM432S-20221213165224

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414004443
Report Date: 12/13/2022
Date Signed: 12/13/2022 04:53:17 PM

Document Has Been Signed on 12/13/2022 04:53 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	GONZALEZ, ADOLFINA		FACILITY NUMBER:	414004443
ADMINISTRATOR:	GONZALEZ, ADOLFINA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(650) 630-2628
CITY:	E PALO ALTO	STATE: CA	ZIP CODE:	94303
CAPACITY:	14	CENSUS: 11	DATE:	12/13/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Licensee, Adolfina Gonzalez		TIME COMPLETED:	05:15 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	On December 13th, 2022 at approximately 1:45pm, Licensing Program Analyst (LPA) Tapia-Mandujano conducted an unannounced required annual inspection. Purpose of the inspection was explained. LPA met with licensee, Adolfina Gonzalez. Present in the facility is licensee and assistant caring for 11 children (3 infants and 9 preschool age). All adults living and working in the home have fingerprint clearance and associated to the facility. Licensee owns home and lives with 4 other adults. 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: Lower Level: Garage, Kitchen, Bedroom #1, portion of Backyard, Storage in the backyard, Side yards, and entire Upper Level: 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 to inspect for health and safety hazards. There were a variety of age appropriate toys and equipment in the home which were in good condition. Home does not have a fireplace. Licensee has pet dog with up to date documentation. There are no pools, and bodies of water in the premises. All cleaning supplies, poisons and other chemicals were stored inaccessible to children. Discipline Policy was discussed. 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 all children's' record. LPA also reviewed facility and personnel records. Licensee's CPR & First Aid Certificate will expire 1/2024. Licensee's Mandated Reporter Training expires 1/2024. Last Emergency drill was conducted 09/2022. Emergency drills must be conducted at least once every six months and should be properly logged. Continued on Page 2...

SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022

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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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: 12/13/2022

NARRATIVE

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Incidental Medical Services (IMS) policy was discussed. Licensee does not offer IMS. 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/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.

Type B violation is issued in accordance with the California Code of Regulations, Title 22, see LIC 809D.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee, Adolfina Gonzalez.

SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022

LIC809 (FAS) - (06/04)

Page: 2 of 7

Document Has Been Signed on 12/13/2022 04:53 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
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: 12/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(b)

Operation of A Family Child Care Home

(b) The home shall be kept clean and orderly, with heating and ventilation for safety and comfort. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in the home was not orderly as there were items that were not for daycare in daycare areas that can potential be tripping hazards and blocking walk paths which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/27/2022
	Plan of Correction
1 2 3 4	Licensee states she will do a deep cleaning of her home and will be disposing of items not needed. A follow up inspection is required.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022

LIC809 (FAS) - (06/04)

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