414004859-12-10-2021-05-CC-LTMO-C9L5HD-20211210185807

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414004859
Report Date: 12/09/2021
Date Signed: 12/10/2021 06:58:21 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:	JIMENEZ, ANDREA		FACILITY NUMBER:	414004859
ADMINISTRATOR:	JIMENEZ, ANDREA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(650) 454-7249
CITY:	EAST PALO ALTO	STATE: CA	ZIP CODE:	94303
CAPACITY:	14	CENSUS: 0	DATE:	12/09/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	12:55 PM
MET WITH:	Andrea Jimenez		TIME COMPLETED:	01:50 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 December 9th, 2021, Licensing Program Analyst (LPA), Leslit Tapia-Mandujano conducted a scheduled Pre-Licensing inspection and met with Licensee, Andrea Jimenez. Licensee has relocated from Facility #414004543 to this current location. Present in the home is licensee. All adults living in the home are fingerprint cleared and associated to the facility. Licensee rents a one story house with three bedroom, one bathroom, and an enclosed backyard. Licensee lives with one adult residents. The hours of operation will be from Monday-Friday 8:00am-5pm. DAY CARE AREA: Living Room, dining room (eating only), Bedroom #2, and Bathroom#1 OFF LIMITS AREA: Bedroom #1, Bedroom #3, Kitchen, Garage, and front and back yard. All off limit areas are properly barricaded. LPA inspected applicant’s home for health and safety hazards. LPA observed the following: Day-care is clean, orderly with a variety of age appropriate toys for the children. All furniture inspected is in good repair. The applicant has a fully stocked First Aid kit and thermometer. The home has no bodies of water or fireplace. Applicant has no pets. Per applicant, there are no guns or weapons in the home. The home has age appropriate equipment available for children in care. Applicant was reminded baby walkers, bouncers, jumpers and any other similar items are to not be used for children in care. Discipline policy was discussed. Isolation area will be in the living room. The home has sufficient lighting and ventilation. Applicant states they will conduct an emergency drill once every six months and log drills. Applicant's CPR & First Aid expire on 11/2023. Mandated Reporter Training Certificate for applicant expire on 11/2023. Applicant was 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 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. Continued on Page 2...

SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8864
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano	TELEPHONE: (650) 350-2554
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021

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: JIMENEZ, ANDREA	FACILITY NUMBER: 414004859
	VISIT DATE: 12/09/2021

NARRATIVE

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During the inspection the following was discussed and reviewed with applicant:
*Safe sleep handout and PIN 20-24 CCP
*Applicant was reminded about having all Staff and Volunteers provide proof of immunization against influenza, pertussis, and measles or qualifies for an exemption.
*Applicant was reminded about the Provider Information Notices (PINs) on CCLD website.
*Capacity limits of a Large Family Child Care License
*Reporting requirements and Covid-19 Technical Assistance

During the inspection, the following was received:
*Proof of completion CPR and First Aid Certificate
*Proof of completion Preventative Health Practices
*Transfer Request Form with Copy of Photo ID
*Proof of Influenza Immunization
This report is discussed and explained to the applicant. Records to be Maintain in the facility was previously explained and copies were provided to applicant to use for all children in care. Mandatory Posting Requirements: License, Emergency Disaster Plan, Earthquake Preparedness Checklist, and Notification of Parents Rights Poster.

Prior to licensure, applicant must complete the following:
*Proof of postings in a prominent Place
*Proof of Control of Property
*Corner bumper protectors on dining room table
*Fire Approval from Menlo Park Fire Department

Copy of this report was emailed to the licensee at MARCOSESPINO7@GMAIL.COM. Signed copy of this report will be kept in the facility file and made available for public review. Desk Duty is available Monday through Friday between 8:00 AM - 5:00 PM at (650) 266-8800. Website for forms and Regulations: www.cdss.ca.gov

SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8864
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano	TELEPHONE: (650) 350-2554
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021

LIC809 (FAS) - (06/04)

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