414004656-1-13-2020-05-CC-JSAI-BKSRQY-20200113121418

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414004656
Report Date: 01/13/2020
Date Signed: 01/13/2020 12:14:35 PM

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:	PEREIRA, KAMILLA		FACILITY NUMBER:	414004656
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 8	DATE:	01/13/2020
TYPE OF VISIT:	Case Management - Licensee Initiated	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Pereira Kamilla		TIME COMPLETED:	12:30 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	LPA Jyoti Saini met with Licensee, Pereira Kamilla for this case management today. Licensee has requested to increase capacity from small family child care home to a large family child care home (FCCH). Licensee and her helper taking care of 8 children today; 6 infants and 2 preschool aged. Licensee states that she, husband, and their minor daughter reside in this home All adults living/working with the children in the home have criminal record clearance.Home is a 3 bedrooms, 2 bathrooms, Living room and dinning room, two level home. Daycare area is: Daycare Room (Family Room), and back yard OFF limit area: Garage and entire upper level. LPA observed the following: There is no change in the day care settings. Fire inspection was done on 01/06/2020 and Licensee has to change the lock on the main door of family room to meet the fire code. Licensee has already installed that. Facility has a working smoke detector, a carbon monoxide detector and a one working telephone. A 2A10BC fire extinguisher is fully charged. First aid supplies are available for children. Licensee's and her helper's CPR/First aid is current. Per licensee, there is no firearms or no weapons in the home. Licensee and her helper has current immunization on the file. There are sufficient, age appropriated toys and children's equipment in the day care area. Activities will be drawing, story time, read, music, outdoor playground and etc. Staff-children ratios discussed with Licensee for a Large Family Child Care Home (FCCH). If there is no helper, Licensee will need to operate within the small FCCH in regard to ratios. If care is provided to the 7th and 8th child for a Small FCCH, or 13th and 14th child for a Large FCCH, the last two children need to be school aged (6 years old). A sample handout is given to Licensee today regarding Small/Large Family Child Care Home Capacity Limitations.

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jyoti Saini	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2020

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: PEREIRA, KAMILLA	FACILITY NUMBER: 414004656
	VISIT DATE: 01/13/2020

NARRATIVE

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Parent's Right and the Emergency Disaster Plan were Posted. Licensee was advised to post the License when she received it.

*Licensee was reminded about having all Staff and Volunteers provide proof of immunization against influenza, pertussis, and measles or qualifies for an exemption. pursuant to Health and Safety code 1596.7995 and 1597.662.

*Licensee was reminded about the Provider Information Notices (PINs) on CCLD website.

*Licensee was reminded about Mandated Reporter Training available on CCLD website (www.ccld.ca.gov or www.mandatedreporterca.com).

Deficiencies cited today under CCR, Title 22, Division 12, Chapter 3. Any licensing report indicating Type A must remain posted for 30 days during the hours of operation.

This report and rights to comment and appeal were discussed with Licensee. This report must be available in the facility for public review. Notice of site visit was observed being posted.
Licensee was advised any additional questions to call Office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website: www.cdss.ca.gov.

After supervisor's review, a license will be recommended for this facility.

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jyoti Saini	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2020

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: PEREIRA, KAMILLA	FACILITY NUMBER: 414004656
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/13/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/14/2020 Section Cited	1 2 3 4 5 6 7	102416.5(b)(2) Staffing Ratio and Capacity.The capacity specified on the license shall be the maximum number of children for whom care may be provided at any one time. This requirement was not met as evidence by observation and records review conducted.
	8 9 10 11 12 13 14	LPA observed licensee supervising total 8 children. Among them there are 6 infants ages ( 9 months - 1.11 months) & 2 preschooler ages ( 4.9- 5 years old). Facility is over capacity.This poses an immediate risk to the health, safety or personal rights of children in care.	8 9 10 11 12 13 14	This facility will be referred to the Licensing Unit Manager for a disposition.Failure to correct the deficiency by due will result in a civil penalty.A follow up visit will be conducted for correction.
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jyoti Saini	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2020

LIC809 (FAS) - (06/04)

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