414004656-12-11-2019-05-CC-JSAI-BJRRQD-20191211121323

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414004656
Report Date: 12/11/2019
Date Signed: 12/11/2019 12:13:36 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: 6	DATE:	12/11/2019
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Kamilla Pereira		TIME COMPLETED:	12:20 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	Licensing Program Analyst (LPA) Jyoti Saini conducted an announced pre licensing inspection today for a change of location and met with Licensee Kamilla Pereira. The facility was previously licensed at 819 Mills Avenue San Bruno CA 94066 License # 414004319. The facility submitted a change of location application on December 4th, 2019. Licensee has applied for Small Family Child Care. During today's visit, Licensee is taking care of 6 children( 5 infants and 1 preschooler). This is unlicensed care. LPA provided Licensee handout on capacity and ratio limits and explained licensee the guidelines. During today's inspection, Licensee's helper entered in the home. LPA noticed that Licensee's helper does not have criminal record clearance. LPA advised that all adults 18 years and older either living or working in the home must have fingerprint clearance. LPA provided LIC 9163 to the helper and explained her that she must have her criminal record Clearance. Helper left the facility with in 10-15 minutes. LPA and Applicant inspected entire home for Health and Safety Hazards. Licensee rents home and lives with husband and minor child .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: LPA observed the home is clean orderly and properly ventilated There are no pools, spas, hot tubs or other bodies of water. Per applicant, there are no firearms or weapons in the home. Cleaning supplies and other potentially harmful items are store inaccessible to children. LPA observed a 2A10BC Fire extinguisher and operable smoke detectors. Napping equipment and bedding was inspected for good condition, appropriate storage and cleanliness. Safe toys play equipment and materials are age appropriate. Evaluation of ill children and isolated area was observed.

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jyoti Saini	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2019

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: 12/11/2019

NARRATIVE

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First Aid Kit is fully stocked and accessible. Applicant states she will conduct an emergency drill once every six months and log drills. Applicant states discipline policy is talking. Applicant’s CPR expires in 12/07/2021. Inspection of required- posted forms was made. Transportation policy and procedures were reviewed for safety requirements. Consultation was provided regarding Smoking prohibition, SIDS, Shaken Baby Syndrome. Applicant is reminded of NO walker, exersaucers, jumpers, bouncers and any similar items to be used for children in care and shall be made inaccessible.

The following forms and publications were discussed with licensee requirement to prominently display 8 ½ X 11 Parent’s Rights Poster (PUB394). Provide parents a copy of the Notification of Parent’s Form (LIC 995A) and the Caregiver Background Check Process Form (LIC 995E). Violations of these requirements are considered serious and subject to progressive civil penalties.

Licensee advised that all adults 18 years and older either living or working in the home must have fingerprint clearance and current TB testing. Failure of an adult 18yrs or older not being fingerprinted is a Violation of Section 102370(d) will result in a citation of a deficiency and an immediate assessment of civil penalties of one hundred dollars ($100) per violation per day for a maximum of five (5) days by the Department.

Licensee was informed that as of September 1, 2016, a person may not be employed or volunteer at a child care facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662.

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jyoti Saini	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2019

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: 12/11/2019

NARRATIVE

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A copy of A Child Care Provider’s Guide to Safe Sheet was provided to the Applicant.

The following corrections will be necessary before a license to operate a small family child care license can be recommended.

There are stairs leading upstairs from family room should be properly barricaded.
Barricade stairs in the backyard.
Criminal record clearance need to be obtained for helper.
Proof of immunized against influenza, pertussis, and measles for licensee and helper.
follow up visit is required.

This report will be kept in the facility file and will be made available for public review upon request. Desk duty is available Monday-Friday, 8:00a.m.-5:00p.m. (650) 266-8800. Website for forms and Regulations: www.cdss.ca.gov

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jyoti Saini	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2019

LIC809 (FAS) - (06/04)

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