414004499-8-17-2022-05-CC-CQUO-CHDR9F-20220817124929

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414004499
Report Date: 08/17/2022
Date Signed: 08/17/2022 12:49:36 PM

Document Has Been Signed on 08/17/2022 12:49 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:	VILLENA, MARIE		FACILITY NUMBER:	414004499
ADMINISTRATOR:	VILLENA, MARIE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(650) 822-8522
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94403
CAPACITY:	14	CENSUS: 5	DATE:	08/17/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:48 AM
MET WITH:	Marie Villena		TIME COMPLETED:	01:00 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 August 17, 2022 at approximately 10:48am, Licensing Program Analyst (LPA) Catrina Quimbo conducted an unannounced, annual inspection. LPA met with licensee, Marie Villena, and explained the purpose of the inspection. Present in the home are licensee, licensee's adult child, licensee's helper (H1) and 5 enrolled children (2 infants and 3 preschool age). All adults living and/or working in the home have a criminal background clearance on file. Hours of operation are Monday to Friday 7:30am to 5:30pm. Children's authorized representatives currently pick up and drop off at the side gate of the house. Licensee lives in the home with adult child. The home includes 3 bedrooms, 2 bathrooms, living room, family room, dining room, kitchen, backyard and garage. The DAY CARE AREAS are bedroom #1 (baby room), bathroom #1, master bedroom (napping room only), family room, living room and backyard. The OFF LIMITS AREAS are bedroom #2 (located between bedroom #1 and bedroom #3), bathroom #2 (located in master bedroom), kitchen, dining room, and shed (located in backyard). All off limits areas are made inaccessible to children by locked doors and/or child safety gates. With licensee, LPA inspected day care areas for health and safety hazards. LPA observed home to be clean, in good repair with proper temperature and ventilation. All cleaning supplies, poisons, and other chemicals were made inaccessible to children, in home's high shelves. Home is equipped with a variety of age appropriate toys and materials that were in good working condition. Home is also furnished with age appropriate materials for crawling and walking children. There was a smoke and carbon monoxide detector, fully charged fire extinguisher and working phone on site. Phone number listed for licensee is current. All accessible, electrical outlets have child safety covers. Per licensee, there are no weapons or firearms in the home. (Continue Report 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: 08/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022

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: VILLENA, MARIE	FACILITY NUMBER: 414004499
	VISIT DATE: 08/17/2022

NARRATIVE

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Entire backyard is enclosed with an at least 5ft high fence. LPA did not observe home to have any pools, spas or bodies of water on the property. The backyard is equipped with appropriate outdoor toys and equipment that were in good working condition. Shed located in backyard is locked and inaccessible to children in care.

LPA reviewed nine children's records which were complete. Children's records have a record of emergency identification information on file. LPA was unable to review H1's completed file. Per licensee, H1 began working in home 8/8/2022. Licensee's CPR/First Aid certificate has expired as of 07/2022, however, has scheduled for a renewed course in 10/2022. Facility will be temporarily closed 09/2022 for vacation. Licensee is aware once CPR course has been completed, licensee will send proof of certification to LPA.

Emergency drills are conducted at least once every six months and are properly logged and documented. Last emergency disaster drill was conducted 08/04/2022. Licensee maintains safe sleep logs for each napping infant. Sleep logs documents time napping infant sleeps and sleeping position.

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: http://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.

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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: 08/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022

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: VILLENA, MARIE	FACILITY NUMBER: 414004499
	VISIT DATE: 08/17/2022

NARRATIVE

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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, Chapt. 1.

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 the licensee, Marie Villena.

SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022

LIC809 (FAS) - (06/04)

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