414004473-11-21-2023-05-CC-JTSE-CXSQ99-20231121105758

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414004473
Report Date: 11/21/2023
Date Signed: 11/21/2023 10:58:24 AM

Document Has Been Signed on 11/21/2023 10:58 AM - 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:	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: 10	DATE:	11/21/2023
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Licensee, Edith Pacheco		TIME COMPLETED:	11:10 AM

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 11/21/2023, at approximately 8:30AM, Licensing Program Analyst (LPA) Jonathan Tse conducted an unannounced required inspection. LPA was granted entry to the facility by Licensee, Edith Pacheco. LPA explained the purpose of the visit. Present in the facility were Licensee, an assistant, and ten preschool age children. The facility is in compliance with capacity requirements. The facility operates as a Spanish immersion program. The facility’s normal operating hours are from 8:00AM to 4:00PM. Extended care is offered from 4:00PM to 6:00PM. The home is a single-level three-bedroom, two-bathroom home. DAY CARE AREAS: Living Room, Dining Area, Bathroom #1 (located in hallway), Bedroom #3 (napping room), and Backyard. OFF-LIMIT AREAS: Bedroom #1, Bedroom #2, Bathroom #2 (located in Bedroom #1), Kitchen, Family Room, and Storage Unit (located in Backyard). LPA and Licensee inspected the home for any health and safety hazards. The home is kept in clean and orderly condition. Children are signed in and out via a sign-in/out sheet. There are age-appropriate toys and learning equipment in the Living Room for children. Per Licensee, there are mats that are used for napping children. Sheets are provided and washed every week. LPA observed a combination carbon monoxide and smoke detector to be operational. The home is equipped with a fully charged 3A40BC fire extinguisher. Cleaning supplies, poisons and other chemicals are stored inaccessible to children. All outlets are covered or obstructed by furniture to not be accessible to children. There is no fireplace in the daycare areas. All off-limits areas are barricaded and kept inaccessible to children. Per Licensee, there are no firearms kept in the home. Continued on Page Two

SUPERVISOR'S NAME: Ali Zebila	TELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Jonathan Tse	TELEPHONE: (650) 464-4927
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023

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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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: PACHECO, EDITH	FACILITY NUMBER: 414004473
	VISIT DATE: 11/21/2023

NARRATIVE

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The backyard is kept in clean condition. LPA did not observe any debris or other loose material to be present. There is sufficient cushioning for children. There is a storage unit located in the backyard that is off-limits and is kept locked to be inaccessible to children. The play equipment in the backyard was observed to be clean and in good repair. There are fences surrounding the backyard that are at least five feet high. There are no pools or other bodies of water located in the facility. There is a dog that is kept separate from children during daycare operating hours.

LPA reviewed two staff files and six children’s files. All children’s files were found to be complete and included immunization records, emergency identification information, and Notification of Parent’s Rights (LIC995A). All staff have current First Aid/CPR and Mandated Reporter Training. Licensee’s First Aid/CPR Training expires 5/2024. Licensee’s Mandated Reporter Training expires 4/2025. There were no Employee Rights (LIC9052) present in the Assistant’s file. LPA discussed requirement to maintain LIC9052 in all employee’s files.

The facility conducts and documents emergency drills every month. The most recent drill was completed on 11/1/23. The facility prepares afternoon snacks for children, and children bring their own lunch from home.

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 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, 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 licensed 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.

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SUPERVISOR'S NAME: Ali Zebila	TELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Jonathan Tse	TELEPHONE: (650) 464-4927
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: PACHECO, EDITH	FACILITY NUMBER: 414004473
	VISIT DATE: 11/21/2023

NARRATIVE

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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-andresources/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.

Incidental Medical Services (IMS) policy was discussed. 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, Licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

There are no deficiencies cited today.

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

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

SUPERVISOR'S NAME: Ali Zebila	TELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Jonathan Tse	TELEPHONE: (650) 464-4927
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023

LIC809 (FAS) - (06/04)

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