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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435700327
Report Date: 03/10/2022
Date Signed: 03/10/2022 12:05:29 PM


Document Has Been Signed on 03/10/2022 12:05 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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612



FACILITY NAME:MABILANGAN, SUSANAFACILITY NUMBER:
435700327
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 4DATE:
03/10/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
10:39 AM
MET WITH:Susana MabilanganTIME COMPLETED:
12:20 PM
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On Thursday March 10, 2022 at 10:39 am, Licensing Program Analyst (LPA) Manel Estoesta conducted an unannounced Case Management Licensee Initiated. License submitted a Capacity Increase Application on 12/28/2021. LPA met with the Licensee and explained the nature of site visit. Present on this visit were 1 infant, 3 preschool children, 1 middle school age child who resides in the home and Licensee's spouse. The home operates from Monday to Friday 7am to 6pm.

LPA toured the facility to conduct a Health and Safety Inspection with the Licensee. The home is a one story home. The home is neat and clean with heating and ventilation for safety and comfort. The ON LIMIT AREAS (accessible to children in care) are the living room, day care playroom, dining room, study room across the hallway bathroom and the hallway bathroom. The OFF-LIMIT AREAS are master bedroom, master bath, the 2 other bedrooms, kitchen, backyard and the garage which will be inaccessible to children in care by closed and or locked doors and or a fence with visual supervision. There is a gate located at the hallway rooms and the kitchen to prevent access to the OFF LIMIT AREAS. The designated isolation area for a child who becomes ill while in care is the study room. There are ample age appropriate toys that appear to be safe and in good condition. There are no pools, hot tubs or any other bodies of water present during today's inspection. All hazardous materials and toxins are kept out of the reach of children and it was observed that there are no toxins or hazardous items accessible today.
The home has a fully charged 3A40BC fire extinguisher, working smoke detector, working carbon monoxide detector and working telephone. The fireplace is being blocked by a furniture to prevent access by children. Per licensee, there are no firearms in the home. The licensee conducts and documents fire and disaster drills twice a year with the last one conducted on 01/04/2022. Licensee does not own the property and maintain the signed the forms LIC 282 AFFIDAVIT REGARDING LIABILITY INSURANCE, LIC 9149 PROPERTY OWNER/LANDLORD CONSENT FAMILY CHILD CARE HOME and LIC 9151 PROPERTY OWNER/LANDLORD NOTIFICATION FAMILY CHILD CARE HOME in the facility file.

SEE 809 C.

SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Manel EstoestaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022
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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: MABILANGAN, SUSANA
FACILITY NUMBER: 435700327
VISIT DATE: 03/10/2022
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The licensee CPR and First Aid certificate and completed on 09/14/2021. The licensee completed the Mandated Reporter General Training and Child Care Providers training online at https://mandatedreporterca.com/ on 06/05/2020. Licensees have records of Measles and Pertussis immunization, Influenza vaccination and TB clearance. LPA reminded Licensee that only the Influenza vaccination can be decline with a written declination.
Facility roster of children was reviewed, and a copy was obtained. Children’s files were reviewed, which included records of receipt for Parents' Rights Notice, Identification and Emergency Information, Consent for Emergency Medical Treatment form, and Immunization. The licensee is in ratio today.
Licensee stated that she does not transport children at this time. Licensee has a current and valid Driver License. Licensee understands that children cannot be left in parked vehicles unattended at any time, the motor vehicles used to transport children in care shall be maintained in safe operating conditions and all vehicle occupants must be secured in an appropriate restraint system.

LPA Estoesta discussed, provided copies of Lead Poisoning Facts Flyer and California Child Safety Seat Law to the licensee. For more information, please follow the links, https://cdss.ca.gov/inforesources/child-care-licensing/water-testing-information and https://www.chp.ca.gov/Programs-Services/Programs/Child-Safety-Seats.

If you have questions regarding a communication you received from CPMB, please visit the Frequently Asked Questions page or contact CPMB at 1-888-422-5669 or Guardian@dss.ca.gov


County of Santa Clara 408-970-2870 and Santa Clara County COVID Support Team 916-262-7553.
If you would like to report an Unusual Incident, please call our Main Office (510) 622 – 2602, there would be two (2) Desk Duty Analyst that are available to assist you.

Contact Information of Santa Clara County Office of Education Childcare Resource & Referral Program 1290 Ridder Park Drive San Jose, CA 95131-2304 Email: childcarescc@sccoe.org Phone: 669-212-KIDS (5437) Hours: Monday – Friday 8:30 a.m.– 4:30 p.m.
https://www.childcarescc.org/child-care-application

SEE 809 C...
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Manel EstoestaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: MABILANGAN, SUSANA
FACILITY NUMBER: 435700327
VISIT DATE: 03/10/2022
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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



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/process.

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.

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.

There are no deficiencies cited on this visit. The home is recommended for a Family Child Care Home Large License, effective 03/10/2022.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Exit interview conducted and report was reviewed with the licensee, Susana Mabilangan.

SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Manel EstoestaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
LIC809 (FAS) - (06/04)
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