414004696-7-12-2021-05-CC-CQUO-C4UU3J-20210712151337

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414004696
Report Date: 07/12/2021
Date Signed: 07/12/2021 03:14:07 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:	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: 12	DATE:	07/12/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Mary Nokom Gonzalez		TIME COMPLETED:	01:30 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	On July 12, 2021 at 11:35am, Licensing Program Analysts (LPAs) April Cowan and Catrina Quimbo conducted an unannounced, annual required inspection. At 11:45am, LPAs met with helper (H1) and explained the purpose of the inspection. Upon LPAs arrival, licensee was not present. Present in the home were 12 children (all preschool age) and 2 staff members. Facility is operating within ratio. All adults working in the home are associated to the facility and have fingerprint clearance. Hours of operation are Monday to Friday from 8:30am to 4:30pm. LPAs conducted a health and safety inspection inside the home. The licensee is licensed for a Large Family Child Care Home. The home consists of 2 bedrooms, 1 bathroom, 1 living room, dining area, kitchen, side yard/driveway, backyard and detached garage. The DAY CARE AREAS are the living room, bedroom#1, dining area, bathroom#1 and backyard area. The OFF-LIMITS AREAS are bedroom #2, kitchen, side yard/driveway and detached garage. All off limit areas are made inaccessible to children by child safety gates and/or child proof door knobs. At 11:50am, LPAs toured day care areas of home with H1. LPAs observed home to be clean and in good repair with proper temperature and ventilation. There were a variety of age appropriate toys and equipment in the home which were in good condition. Home does not have a fireplace or bodies of water. Outdoor toys and equipment in the backyard were age appropriate and in good working condition. All cleaning supplies, poisons, and other chemicals were stored inaccessible to children. There was a working smoke detector and carbon monoxide detector, and a fully charged fire extinguisher. Mobile phone number listed for Licensee is current. Per H1, there are no weapons or firearms in the home. Continue Report on Page 2.....

SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8864
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: (650) 393-8293
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021

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: GONZALEZ, MARY NOKOM	FACILITY NUMBER: 414004696
	VISIT DATE: 07/12/2021

NARRATIVE

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LPAs reviewed three children's records and two staff records. All children have a record of emergency identification information on file. At 12:24pm, Licensee, Mary Nokom Gonzalez, arrived at facility. Staff records were reviewed. Licensee's Pediatric First Aid/CPR is current and will expire 05/2022. Emergency drills are conducted and properly logged. The last emergency drill was conducted 09/30/2019. Licensee was reminded emergency drills must be conducted and documented at least once every 6 months.

Incidental Medical Services (IMS) was discussed. Licensee has no children who need services at this time. 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 Americans with Disabilities Act (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: www.ada.gov/childqanda.htm.

During inspection:
-Licensee was reminded, as of September 1, 2016, all Staff and Volunteers must provide proof of immunization against pertussis, measles, and influenza, or qualifies for an exemption, pursuant to Health and Safety code 1596.7995 and 1597.622.
-Licensee was reminded about Mandated Reporter training available on CCLD website. Training must be completed every 2 years by all staff hired. Training can be taken online at www.mandatedreporterca.com. If training is not available in native language, a statement can be written stating exemption until the translation is available.
-Licensee was reminded about the Provider Information Notices (PINs) on CCLD website.
-Licensee was advised for any additional questions to contact CCLD office, Monday to Friday, 8:00am - 5:00pm, (650) 266-8800 or 1 (844) 538-8766. Website: www.cdss.ca.gov.

LPA requested proof of:
-Required posters posted in a prominent place. (LIC610A and PUB394)
-All staff and helpers have records of required immunizations.

After today’s inspection, an exit interview and Plan of Correction (POC) was conducted with licensee, Mary Nokom Gonzalez. Licensee was issued a Type B citation for not conducting and documenting emergency drills at least once every six months. Please refer to 809D for more information.

This report is public and can be reviewed. A copy of this report was provided to the licensee with Appeal Rights and Procedures and Notice of Site Visit via email at kubomontessori2006@gmail.com. Licensee was reminded that Notice of Site Visit (LIC9213) shall be posted in a prominent place in facility for 30 days during the hours of operation. Failure to maintain postings as required will result in a civil penalty of $100.

SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8864
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: (650) 393-8293
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021

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: GONZALEZ, MARY NOKOM	FACILITY NUMBER: 414004696
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/12/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/16/2021 Section Cited	1 2 3 4 5 6 7	102417(g)(9)(A)(1) Operation of a Family Child Care Home...Each family child care home shall conduct fire drills and disaster drills at least once every six months. The Licensee shall document the drills... This requirement was not evidenced as by:
	8 9 10 11 12 13 14	Based on obersvation, interview and file review, the last emergency drill recorded was dated 09/30/2019. This poses a potential Health, Safety and or Personal Rights risk to children in care.	8 9 10 11 12 13 14
	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: Cindy Interiano	TELEPHONE: (650) 266-8864
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: (650) 393-8293
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021

LIC809 (FAS) - (06/04)

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