414004705-7-8-2020-05-CC-CINO-BRBTYM-20200708150859

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414004705
Report Date: 07/08/2020
Date Signed: 07/08/2020 03:10:01 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:	JIMENEZ-PELAEZ, SILVIA		FACILITY NUMBER:	414004705
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 0	DATE:	07/08/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Applicant, Silvia Pelaez		TIME COMPLETED:	12:15 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 PreLicensing inspection this day, arriving at 10:30a and met with Applicant, Silvia Pelaez. LPA and Applicant inspected entire home for Health and Safety Hazards. Applicant owns home, which is a 3 bedroom, 2 bathroom, single level (front) Duplex. Applicant lives with her Husband and Adult Son. Daycare area is: Living Room, Bedrooms #1, #2, and #3, Dining area, Family Room/Playroom, Bathroom#2, and Side yard. OFF limit areas: Front yard, Bathroom #1, Kitchen, Garage, and Backyard (pass by only). All off limit areas, including all closets, are properly barricaded. First Aid Kit is fully stocked and accessible. Home has a fully charged fire extinguisher, and multiple functioning smoke and carbon monoxide detectors. All harmful and sharp objects are made inaccessible from children in care. Applicant states there are no guns or weapons in the home. The home is clean and orderly with sufficient lighting and ventilation. Applicant states she will conduct an emergency drill once every six months and log drills. Applicants’ CPR expires in 06/2022. Home has age appropriate toys and equipment available for the children in care. Applicant states discipline policy is redirection. Postings will be posted near main door. 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. Applicant is advised all adults, 18 years and older living in the home, helper, or assistant must have finger print clearance and must be associated to the facility by submitting an LIC 9182 with copy of CDL or Ca. ID prior to having any contact with children in care failure to do so could result in an immediate civil penalty of $100.00 each day. Applicant 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. 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: 07/08/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2020

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: JIMENEZ-PELAEZ, SILVIA	FACILITY NUMBER: 414004705
	VISIT DATE: 07/08/2020

NARRATIVE

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Page 2. . .

Incidental Medical Services (IMS) policy was discussed. 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 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: http://www.ada.gov/childqanda.htm

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

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

Applicant was reminded of Mandated Reporter Training available on CCLD website or at www.mandatedreporterca.com

This report is discussed and explained to the Applicant. Records to be Maintain in the facility is explained and left with the Applicant (in English and Spanish) to use for all children in care. Mandatory Posting Requirements: License, Emergency Disaster Plan, and Notification of Parent's Rights Poster.

Capacity limits of a Small Family Child Care License has been reviewed.

Applicant has provided:
*Applicant’s immunization

Small Family Child Care Home License is approved and will be effective as of today, 07/08/2020.

>This report will be emailed to the Applicant. 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: 07/08/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2020

LIC809 (FAS) - (06/04)

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