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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004443
Report Date: 11/21/2024
Date Signed: 11/21/2024 01:07:10 PM

Document Has Been Signed on 11/21/2024 01:07 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:GONZALEZ, ADOLFINAFACILITY NUMBER:
414004443
ADMINISTRATOR/
DIRECTOR:		GONZALEZ, ADOLFINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 630-2628
CITY:E PALO ALTOSTATE: CAZIP CODE:
94303
CAPACITY: 14TOTAL ENROLLED CHILDREN: 33CENSUS: 8DATE:
11/21/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Licensee, Adolfina GonzalezTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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On November 21st, 2024 at approximately 8:45am, Licensing Program Analysts (LPAs) Tapia-Mandujano and Naves conducted an unannounced annual/random inspection. LPAs met with Licensee, Adolfina Gonzalez and explained the purpose of the inspection. Present in the facility are licensee and three assistants caring and supervising 8 children (2 infants and 6 preschoolers). All adults present today have fingerprint clearance and are associated.

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- Sunday and open 24 hours. Facility was inspected and the Daycare areas are: Lower level: Living room, Dining area, Family Room, Bedroom #1, Bathroom #1, Front yard, and portion of the Back yard. Off limit areas are: Lower Level: Garage, Kitchen, 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.



LPAs observed home to be clean and 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. Home does not have a fireplace. Per licensee, there is a pet dog in the home with proper documentation. There were no pools, spas or bodies of water on the property. LPAs advised licensee about water safety hazards. All cleaning supplies, poisons, and other chemicals were stored inaccessible to children. Discipline Policy was discussed. Isolation Area a sick child will be in the bedroom.

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 updated in the system. Per Licensee, there are no weapons or firearms in the home. Infant children are sleeping in pack and plays in the main living room or in the bedroom. Sleep logs were only being logged for each child under 12 months. LPAs advised Sleep logs are for all infant children up until 24 months (Technical Violation Issued).

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SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: GONZALEZ, ADOLFINA
FACILITY NUMBER: 414004443
VISIT DATE: 11/21/2024
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LPAs reviewed 8 children's file and facility files. Children's files were complete. Facility files were completed. Licensees CPR & First Aid Certificate expires on 01/2025. Licensee's Mandated Reporter Certificate has expired 10/2025. Last emergency drill was conducted 08/2024. LPAs reminded that Emergency Drills must be conducted at least once every six months and be properly logged. All the required posting documentation, such as the facility license, Notification of Parental Rights have been placed in a prominent area for parents or representatives to review.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website atwww.cdss.ca.gov/inforesources/community-care-licensing/inspection-process

Licensee was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days 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.



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SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: GONZALEZ, ADOLFINA
FACILITY NUMBER: 414004443
VISIT DATE: 11/21/2024
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Incidental Medical Services (IMS) policy was discussed. Licensee does not offer IMS at this time. For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the licensee, Adolfina Gonzalez, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS on 11/21/24.

***Deficiencies were not cited today under California Code of Regulations, (Title 22, Div. 12, Ch 3)



A Notice of Site Visit was given and must be posted for 30 days.

Exit interview conducted and report was reviewed with the licensee, Adolfina Gonzalez. This report was translated into Spanish by Certified Bilingual LPA Tapia-Mandujano.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
LIC809 (FAS) - (06/04)
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