414004696-5-29-2020-05-CC-CINO-BQ3KZL-20200529082056

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414004696
Report Date: 05/28/2020
Date Signed: 05/29/2020 08:22:29 AM

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:	GONZALEZ, MARY NOKOM		FACILITY NUMBER:	414004696
ADMINISTRATOR:	GONZALEZ, MARY NOKOM		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(650) 312-1208
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94403
CAPACITY:	14	CENSUS: 0	DATE:	05/28/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Licensee, Mary Nokom Gonzalez		TIME COMPLETED:	01:45 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), Cindy Interiano, conducted a scheduled relocation PreLicensing inspection this day, arriving at 12:30 and met with Licensee, Mary Nokom Gonzalez. Licensee has relocated from facility #414002195 to this current location. LPA and Licensee inspected entire home for Health and Safety Hazards. Licensee owns home, which is a 2 bedroom, 1 bathroom, duplex unit (back unit). Licensee has provided proof of control of properly. Daycare areas are: Living Room, Bedroom #2, and Bathroom #1, Dining area, and Backyard. OFF limit areas: Master Bedroom #1, Kitchen area, Side yard/Driveway, and detached Garage. All off limit areas are properly barricaded. Home has a working smoke and carbon monoxide detector, a working telephone, and a fully charged fire extinguisher. First Aid kit is fully stocked and accessible. Home has no Fireplace or bodies of water. All harmful and sharp objects are made inaccessible from children in care. Licensee states there are no guns or weapons in the home. Home is clean and orderly, with sufficient lighting and ventilation. Licensee states she conducts an emergency drill once every six months and logs drills. Licensee states discipline policy is redirection. Licensee’s CPR expires in 12/2021. Postings are posted near main entrance of the home. Licensee is reminded of NO walker, exersaucers, jumpers, bouncers, and any similar items to be used for children in care and shall be made inaccessible. Licensee is advised all adults, 18 years and older living in the home, Helper, or assistant must have criminal record clearance and must be associated to the facility prior to having any contact with the children in care and failure to do so could result in an immediate civil penalty of $100.00 each day. See Page 2 . . .

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2020

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 2

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: GONZALEZ, MARY NOKOM	FACILITY NUMBER: 414004696
	VISIT DATE: 05/28/2020

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
26
27
28
29
30
31
32

Page 2. . .

During inspection,
*Incidental Medical Services (IMS) policy was discussed.
*Licensee was reminded about having all Staff and Volunteers provide proof of immunization against influenza, pertussis, and measles or qualifies for an exemption.
*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). Licensee has Mandated Reporter Training Certificate on file.
*Licensee was reminded about ‘Safe Sleep’ practices.

This report is discussed and explained to the Licensee. Records to be Maintain in the facility was previously explained and provided to Licensee (in English and Spanish) to use for all children in care. Mandatory Posting Requirements: License, Emergency Disaster Plan, and Notification of Parents Rights Poster.

LPA also provided Technical Assistance for Covid-19 guidelines.

Licensee has applied for a Large capacity Family Child Care License. Due to the Shelter-in-Place, Fire inspections are currently not being conducted.

Capacity limits of a Small and Large License has been reviewed with Licensee.

Licensee is advised that she may start operating at a Small capacity license as of today, 05/28/20, until Fire inspection can be conducted.
Once the fire clearance is received, a Large capacity license will be issued.

>This report will be emailed to the Licensee. This report must be available in the facility for public review. Any additional questions to call Office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website: www.cdss.ca.gov

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2020

LIC809 (FAS) - (06/04)

Page: 2 of 2