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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004705
Report Date: 07/12/2021
Date Signed: 07/12/2021 04:00:21 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:PELAEZ, SILVIAFACILITY NUMBER:
414004705
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 5DATE:
07/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Silvia PelaezTIME COMPLETED:
02:15 PM
NARRATIVE
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On July 12, 2021 at 11:45AM, Licensing Program Analyst(LPA) Tapia-Mandujano conducted a Random Annual unannounced inspection at facility and met with licensee. Purpose of the inspection was explained. Present in the home are licensee, licensee's husband, licensee's adult son, and 5 children (4 infants and 1 preschool age).

Licensee owns home, which is a 3 bedroom, 2 bathroom, single level (front) Duplex. Hours of operation are Monday-Friday from 8AM-5PM. Daycare area is: Living Room, Bedrooms #1, #2, and #3, Dining area, Family Room/Playroom, Bathroom#1 & 2, and Side yard. OFF limit areas: Front yard, Kitchen, Garage, and Backyard (pass by only).

LPA observed home to be clean and in good repair with proper temperature and ventilation. There is a variety of age appropriate toys and equipment in the home which are in good condition. There are no pools, spas, or bodies of water on the property. Home has a fireplace that is properly barricaded. Side yard is fenced and properly barricaded leading to off limit areas. All cleaning supplies, poisons, and other chemicals are stored inaccessible to children. There is a working smoke detector and carbon monoxide detector, a fully charged fire extinguisher, and a working telephone. Per Licensee, there are no weapons or firearms in the home. Licensee's CPR & First Aid expires on 6/2022. Licensee's Mandated Reporter certificate expires on 7/2022. Per licensee there are two dogs in the home that are kept separate from children. Children’s files were reviewed.

During inspection,
-Licensee was given information regarding PIN 20-24-CCP Safe Sleep Regulation and Lead Poisoning Facts Flyer.
-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.
-Licensee was reminded about the Provider Information Notices (PINs) on CCLD website.

Continued on Page 2...
SUPERVISOR'S NAME: Cindy InterianoTELEPHONE: (650) 266-8864
LICENSING EVALUATOR NAME: Leslit Tapia-MandujanoTELEPHONE: (650) 350-2554
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)
Page: 1 of 3
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: PELAEZ, SILVIA
FACILITY NUMBER: 414004705
VISIT DATE: 07/12/2021
NARRATIVE
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**See following page for deficiencies cited against the facility today under CCR,Title 22, Div. 12, Chapt. 1

Type “A” violations were issued today. Licensee is advised to provide a copy of the Evaluation Report and all Type “A” Deficiencies cited, to the parents and guardians of children currently enrolled in care and to parents of newly enrolled children during the next 12 months. A signed and dated LIC 9224 shall be maintained in all Children's files. Notice of site Visit was posted and should remain posted for 30 days, failure to post will result in an immediate civil penalty.

**Today’s report dated 07/12/2021, rights to comment and appeal, and Notice of Site visit will be emailed to Licensee at SILVIAPELAEZ5@YAHOO.COM by close of business today, 07/12/2021.

A copy of this report will be emailed to SILVIAPELAEZ5@YAHOO.COM . This report will be kept in the facility file and will be made available for public review upon request. Desk Duty is available Monday through Friday between 8 AM - 5 PM at (650) 266-8800.
SUPERVISOR'S NAME: Cindy InterianoTELEPHONE: (650) 266-8864
LICENSING EVALUATOR NAME: Leslit Tapia-MandujanoTELEPHONE: (650) 350-2554
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)
Page: 2 of 3
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: PELAEZ, SILVIA
FACILITY NUMBER: 414004705
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/12/2021
Section Cited

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102416.5(a) Staffing Ratio and Capacity. (a) The capacity specified on the license shall be the maximum number of children for whom care may be provided at any one time. This requirement is not met by evidence by:
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LPA observed licensee care for 4 infants and 1 preschool age child. This poses an immediate Health and Safety risk to children in care.
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Licensee will update facility roster and children's schedule, showing compliance to the capacity requirements as stated on the license. A follow-up inspection will be conducted.

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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: Cindy InterianoTELEPHONE: (650) 266-8864
LICENSING EVALUATOR NAME: Leslit Tapia-MandujanoTELEPHONE: (650) 350-2554
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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