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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434405634
Report Date: 03/27/2023
Date Signed: 03/27/2023 12:17:06 PM


Document Has Been Signed on 03/27/2023 12:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612



FACILITY NAME:GASPAY, MAYBELINEFACILITY NUMBER:
434405634
ADMINISTRATOR:GASPAY, MAYBELINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 857-0126
CITY:PALO ALTOSTATE: CAZIP CODE:
94303
CAPACITY:14CENSUS: 4DATE:
03/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Maybeline GaspayTIME COMPLETED:
12:28 PM
NARRATIVE
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On March 27, 2023 at approximately 9:00am Licensing Program Analyst (LPA) Russ Haderer arrived for an unannounced annual inspection. Present for the inspection was licensee Maybeline Gaspay, her fingerprint cleared and TB tested assistant and 4 children in care (one infant 22 months old; one 2-year old; two 3-year old). The facility is in ratio today. The hours of operation remain at 8:00am to 5:00pm.

The facility is a 4-bedroom, 3 bath single story family home with a front and back yard area and a detached garage house. There is a screened fireplace in the living room and blocked by a small end table to prevent access.

The changing table is in the activity area. All documents required to be posted were present: License, parent’s rights, emergency disaster plan, earthquake preparedness.

ISOLATION AREA will be in the front living room on a couch away from other children in care until their parents can come and pick them up.

On-limit-areas include: Living room; family room (converted to childcare area); ½ bathroom in family room; backyard patio area. Licensee reminded that other than wipes or things used for the children in the on limits bathroom, they need to be empty of most all items (or locked up) such as cleaning products etc.

Off-limit-areas include: Kitchen; all three bedrooms of the home; house bathroom and masted bathroom; side yards of the home; detached garage house. The off-limit areas will be inaccessible by child gates, closed and/or locked doors, or child supervision.

There is a fully charged 3A40BC fire extinguisher located in the daycare areas. The facility has a working (tested) dual smoke and carbon monoxide detectors. Per licensee, there are no firearms in the home. The licensee conducts Fire/Disaster Drills; however, the log indicates the last drill was conducted 8/12/2020 – see LIC809D for deficiency.

SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2023
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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: GASPAY, MAYBELINE
FACILITY NUMBER: 434405634
VISIT DATE: 03/27/2023
NARRATIVE
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There were ample age appropriate toys that were observed to be safe and in good condition. The home is neat and clean, with heating and ventilation for safety and comfort. LPA did not observe any hazardous materials, or toxins accessible to children on the premises during the inspection.

Children's files were reviewed, the facility roster was reviewed, and a copy obtained. Two of six files reviewed were missing the singed and dated proof of receipt from parents – see LIC809D for deficiency. Safe sleep observation is made for infants, but documentation has not been maintained but will be going forward. Going forward, sleep logs must be maintained for all infants from birth to 24 months.

The licensee’s Pediatric CPR/First Aid certificate expired on January 13, 2023 – see LIC809D for deficiency. Mandated reported certificate expired and has not been renewed – see LIC809D for deficiency. Licensee and assistant did not have proof of pertussis (or a booster) in their files – see LIC809D for deficiency. LPA reminded the licensee that CPR/1st Aid and Mandated Reporter training must be renewed every two years. Baby bouncers & drop-down cribs are not allowed at the day-care facility.

The licensee owns the property. Licensee carries liability insurance through ACC and is current through June 15, 2023,



Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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

SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: GASPAY, MAYBELINE
FACILITY NUMBER: 434405634
VISIT DATE: 03/27/2023
NARRATIVE
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LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

There were 5 Type B deficiencies issued today for:

- Fire/earthquake drills have not been done every six months

- LIC995 Parent’s Rights proof of receipt form signed and dated by parents was not in the child’s file.

- CPR/1st Aid certificate expired

- Mandated Reporter certificate expired

- Licensee and assistant’s files were missing proof of pertussis vaccination or booster

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee Maybeline Gaspay.

SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/27/2023 12:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612


FACILITY NAME: GASPAY, MAYBELINE
FACILITY NUMBER: 434405634

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that the last disaster drill was completed on August 12, 2020 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2023
Plan of Correction
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Licensee to conduct a disaster drill (fire or earthquake) with the children. Going forward licensee to complete a drill at lease once every six months.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that current Mandated Reporter certificates (child care providers AB1207) was not completed and/or done for licensee and assistant which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2023
Plan of Correction
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Licensee and assistant to go to www.mandatedreporterca.com and complete the Child Care Providers AB1207. Going forward, this certificate must be renewed every two years.
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: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2023
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 03/27/2023 12:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612


FACILITY NAME: GASPAY, MAYBELINE
FACILITY NUMBER: 434405634

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that licensee's CPR/1st Aid training expired on January 13, 2023. No current certificate available for assistant which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2023
Plan of Correction
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Licensee and assistant to complete CPR/1st Aid training. Going forward, this certificate must be renewed every two years.
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that licensee and assistant did not have proof of pertussis vaccination or a booster in their personal file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2023
Plan of Correction
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Licensee and assistant provide proof or tdap (or pertussis) vaccination or a booster shot.
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: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2023
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 03/27/2023 12:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612


FACILITY NAME: GASPAY, MAYBELINE
FACILITY NUMBER: 434405634

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)
Admission Procedures and Parental and Authorized Representative's Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on file review, the licensee did not comply with the section cited above in that two of six children's files reviewed found they were missing the signed proof of receipt for the LIC995A Parent's Rights form which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2023
Plan of Correction
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Licensee to collect signed proof of receipt for the LIC995A Parents Rights form.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2023
LIC809 (FAS) - (06/04)
Page: 6 of 6