414004473-5-5-2022-05-CC-CQUO-CE5RZF-20220505132748

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414004473
Report Date: 05/05/2022
Date Signed: 05/05/2022 01:28:39 PM

Document Has Been Signed on 05/05/2022 01:28 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:	PACHECO, EDITH		FACILITY NUMBER:	414004473
ADMINISTRATOR:	PACHECO, EDITH		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(650) 389-4511
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94403
CAPACITY:	14	CENSUS: 12	DATE:	05/05/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Edith Pacheco		TIME COMPLETED:	01:45 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 May 5, 2022 at approximately 11:40am, Licensing Program Analyst (LPA) Catrina Quimbo conducted an unannounced, annual inspection. LPA met with licensee, Edith Pacheco, and explained the purpose of the inspection. Present during inspection included licensee, Helper #1 (H1), Helper #2 (H2), and 12 enrolled children (all preschool age). Facility is operating within capacity ratio and requirements on this date. All adults living and/or working in the home have criminal record clearance on file. Hours of operation are Monday to Friday 8:00am to 6:00pm. Licensee rents the home which is a single-level, family home that includes 3 bedrooms, 2 bathrooms, living room, dining area, family room, kitchen, back yard and front yard. The DAY CARE AREAS are the living room, dining area, bathroom #1 (located in hallway), bedroom #3 (napping room), and backyard. The OFF-LIMIT AREAS are bedroom #1, bedroom #2, bathroom #2 (located in bedroom #1), kitchen, family room, and storage unit in backyard. All off limit areas are properly barricaded by child safety gates and/or child safety locked door handles. At approximately 12:00pm, LPA toured day care areas of home with licensee. Facility operates as a Spanish immersion program. LPA observed home to be in good repair with proper temperature and ventilation. Day care areas do not include a fireplace. There were a variety of age appropriate toys and equipment in the home that were in good condition. Licensee utilizes mats for enrolled children during nap time. All accessible electrical outlets are properly covered with child safety covers. Cleaning supplies, poisons and other chemicals were stored inaccessible to children in off limit areas. Outdoor area does not include any pools, spas or bodies of water. Storage unit located in backyard is properly locked, inaccessible to children. The entire backyard is enclosed with an at least 5 ft. high fence. Backyard was observed to have age appropriate equipment that were in good working condition. (Continue on Page 2...)

SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022

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: PACHECO, EDITH	FACILITY NUMBER: 414004473
	VISIT DATE: 05/05/2022

NARRATIVE

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There was a smoke detector and carbon monoxide detector, a fully charged fire extinguisher 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 twelve children’s records which were complete. Children’s files have a record of emergency identification information on file as well as required immunizations. LPA reviewed Licensee, H1 and H2's files as well. Licensee, H1 and H2 have proof of required immunizations. Licensee's Pediatric First Aid/CPR has expired as of 03/2022. Licensee and H2 are registered to renew CPR course 05/06/2022. Last emergency drill was conducted 05/04/2022. Emergency drills are conducted at least once every six months and are properly logged.

During Inspection:
- Licensee was given information regarding Lead Poisoning Facts Flyer.
-LPA reviewed capacity and ratios of small and large license. Licensee was reminded that when she is working alone, licensee must operate as a small license. Licensee was reminded that when operating at a Large capacity, there must be a helper present.
-Licensee was reminded, as of September 1, 2016, all Staff and Volunteers must provide proof of immunization against pertussis, measles, and influenza, or qualifies for an exemption, pursuant to Health and Safety code 1596.7995 and 1597.622.
-Licensee was reminded about Mandated Reporter training available on CCLD website. Training must be completed every 2 years by all staff hired. Training can be taken online at www.mandatedreporterca.com.
-Licensee was reminded about the Provider Information Notices (PINs) on CCLD website.
-Licensee was advised for any additional questions to contact CCLD office, Monday to Friday, 8:00am - 5:00pm, (650) 266-8800 or 1 (844) 538-8766. Website: www.cdss.ca.gov.

Incidental Medical Services (IMS) policy was discussed. 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.

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SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022

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: PACHECO, EDITH	FACILITY NUMBER: 414004473
	VISIT DATE: 05/05/2022

NARRATIVE

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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.

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

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

An exit interview conducted and report was reviewed with the licensee, Edith Pacheco.

SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022

LIC809 (FAS) - (06/04)

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