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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004443
Report Date: 01/09/2023
Date Signed: 01/09/2023 02:22:07 PM


Document Has Been Signed on 01/09/2023 02:22 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, ADOLFINAFACILITY NUMBER:
414004443
ADMINISTRATOR:GONZALEZ, ADOLFINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 630-2628
CITY:E PALO ALTOSTATE: CAZIP CODE:
94303
CAPACITY:14CENSUS: 11DATE:
01/09/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Licensee, Adolfina GonzalezTIME COMPLETED:
02:45 PM
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On January 9th, 2023 at approximately at 12:50pm, Licensing Program Analyst (LPA) Tapia-Mandujano conducted an unannounced, plan of correction (POC) and a Case Management visit. LPA met with licensee, Adolfina Gonzalez, and explained the purpose of the visit. Present during inspection are licensee assistant and licensee caring for a total of 11 children ( 4 infants and 7 preschool age). Facility is operating within capacity limits at this moment.

On December 13th, 2022, LPA met with licensee to conduct an unannounced, annual inspection at facility. During annual inspection, LPA observed facility to not be orderly and clean as there were items that were not for daycare in daycare areas that can potential be tripping hazards and items blocking the pathways to entrance/exits. A POC was developed with licensee.

As of this date, LPA observed the home was more organized and the pathways for entrances and exits are more accessible. At approximately at 1:15pm, LPA observed all required licensing documents to be properly posted in the facility. LPA spoke to licensee about maintaining the home orderly and cleaned.

Deficiency cited on December 13th, 2022 has been cleared. LPA provided licensee copy of POC letter. No deficiencies were cited today.

At approximately, 1:30pm, LPA inspected Bedroom #1 to be added as part of Daycare Areas. LPA observed Bedroom #1 to have three pack and plays and will be used for sleeping only or to separate a sick child as parents pick up. LPA explained door must be maintained open at all times, and Bedroom #1 shall be used for intended purposes only.

LPA has approved Bedroom #1. New DayCare Areas are as follow: 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.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with licensee, Adolfina Gonzalez.
SUPERVISOR'S NAME: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Leslit Tapia-MandujanoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2023
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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