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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004656
Report Date: 11/29/2021
Date Signed: 11/29/2021 02:51:54 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, KAMILLAFACILITY NUMBER:
414004656
ADMINISTRATOR:PEREIRA, KAMILLAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 483-6282
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY:14CENSUS: 5DATE:
11/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensee, Kamilla PereiraTIME COMPLETED:
12:30 PM
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Licensing Program Analysts (LPAs) Jyoti Saini and Jennifer Yee met with Licensee, Kamilla Pereira for an unannounced Annual Random Inspection. LPAs disclosed the purpose of the inspection and was granted entry into the facility by the licensee. Present in the facility is licensee and helper supervising 2 infants and 3 Preschoolers. Licensee rents home and lives with her minor daughter and husband. Home is 3 bedrooms, 2 bathrooms, Living room and dining room, two level home. Daycare area is: Daycare Room (Family Room downstairs), and half back yard OFF limit area: Garage and entire upper level and half backyard. Licensee is within capacity limits of a Large License. The hours of operation are 7:30 AM-5:30 PM, Monday -Friday. All off limit areas are properly barricaded.
LPAs observed the following: Day-care area is clean, orderly, and equipped with age appropriate toys and equipment for children, indoors and outdoors. Home has a working telephone, a working smoke and a fire extinguisher that meets the minimum requirements. There are no bodies of water or Fireplace in the Day-care area. There are child size tables and chairs for snack and activities. There are ample of age appropriate toys that appear to be safe and in good condition. LPA did not observe any hazardous materials or toxins accessible to children during today’s inspection. Children bring their own snacks. The napping room had cots in good condition and each child have their separate blankets. All trash cans and recycle bins have tight fitted lids. The outdoor play area is fenced. Licensee states there are no guns or weapons of any kind in the home.

Licensee conducted last emergency drill on 07/2021. Discipline policy is redirection. LPAs reviewed children’s files. All the files are complete and up to date. All required postings are properly posted.



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SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jyoti SainiTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 5
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: 11/29/2021
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Licensee was reminded about Mandated Reporter training available on CCLD website. Training must be completed every 2 years.Training can be taken online at www.mandatedreporterca.com

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.

LPAs 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. LPAs also informed licensee [facility representative] 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.

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

Exit interview conducted and report was reviewed with the licensee Kamilla Pereira.

SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jyoti SainiTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2021
LIC809 (FAS) - (06/04)
Page: 5 of 5
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: 11/29/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations,interviews, and record reviews the licensee did not comply with the section cited above. Licensee and helper have CPR trainning through invalid Credentials which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/31/2021
Plan of Correction
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Licensee must take an approved course through either: the American Red Cross, American Heart Association or a course approved and certified by EMSA, Emergency Medical Services Authority, by due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jyoti SainiTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5