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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214005542
Report Date: 03/07/2024
Date Signed: 03/07/2024 05:04:13 PM

Document Has Been Signed on 03/07/2024 05:04 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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:DURAN, MARIA C.FACILITY NUMBER:
214005542
ADMINISTRATOR:DURAN, MARIA C.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 521-9419
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 12DATE:
03/07/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Maria DuranTIME COMPLETED:
05:10 PM
NARRATIVE
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On 3/7/2024 at 12:55PM., Licensing Program Analysts (LPA), Luis Gomez met with Assistant, Elida Maldonado. The purpose of today’s inspection was explained and was for an unannounced/ random Inspection. Present was the helper and 2 staff caring for 12 children. Licensee’s days and hours of operations are Monday- Friday 8:00AM- 5:30PM., Areas of the home used for care are: Living room (Playroom); Dining Area; Bedroom #1; Bathroom #1; Backyard Patio and Lower Level. Areas of the home designated as off- limits are: Kitchen, Bedroom #2 and Bathroom #2. LPA inspected home for health and safety hazards.

LPA observed the following: Facility was clean, with playthings available for the children. Ground surfaces were clear of obstructions or potential hazards. The children’s furniture, materials, and books were in good repair. Child safety locks had been installed on accessible cabinets in bathroom. The licensee’s dining area has several chairs and table, scaled to the proper size. For scheduled nap, LPA observed stackable cots in bedroom #1. Per licensee, napping linens are laundered on-site every day. Facility toilet and hand washing fixture in bathroom #1 were in operating condition. Licensee's home was a comfortable temperature, with ventilation and lighting. Home had functioning telephone service; carbon monoxide detector; smoke detector; and fire extinguisher: 2A:10:BC.

LPA reviewed outdoor play areas including Patio and Lower Level. Area was completely enclosed with plaything in good repair. Home does not have any pools, fishponds, jacuzzi or bodies of water. (REFER TO 809C, FOR CONT)

SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2024
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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Document Has Been Signed on 03/07/2024 05:04 PM - It Cannot Be Edited


Created By: Luis Gomez On 03/07/2024 at 03:55 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: DURAN, MARIA C.
FACILITY NUMBER: 214005542

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
102370(d)
Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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At 1:30PM., Based on observations, interview, and record review, LPA confirmed individual present (S3) without criminal record clearance or association. This poses an immediate health and safety risk to children in care.
POC Due Date: 03/08/2024
Plan of Correction
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Licensee will ensure all assistant (S2) receive criminal record clearance and association by the due date: 3/8/2024.
Proof of correction will be submitted to the Department via email.
Request Denied
Type A
Section Cited
CCR
102416.5(d)(1)
Staffing Ratio and Capacity
(d) For a Large Family Child Care Home, the maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home, including children under age 10 who reside at the licensee's home and the assistant provider's children under age 10, shall be either: (1) Twelve children, no more than four of whom may be infants; or

This requirement is not met as evidenced by:
Deficient Practice Statement
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At 2:50PM., Based on record review, interview and observations, LPA confirmed licensee operating over capacity with 12 children (6 infants) in care. This poses an immediate health and safety risk to children in care.
POC Due Date: 03/08/2024
Plan of Correction
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Licensee will reduce infant-age children to required limit of 4, by the due date: 3/8/2024. Licensee will submit updated: LIC9040, Client Roster to the Department.
Proof of correction will be submitted via email.
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:Marie Rodriguez
LICENSING EVALUATOR NAME:Luis Gomez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024


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Document Has Been Signed on 03/07/2024 05:04 PM - It Cannot Be Edited


Created By: Luis Gomez On 03/07/2024 at 03:55 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: DURAN, MARIA C.
FACILITY NUMBER: 214005542

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(a)
Child's Records
(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).

This requirement is not met as evidenced by:
Deficient Practice Statement
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At 2:00PM., Based on record review, observations, and interview, LPA confirmed child’s file (C7) missing from facility records. This poses a potential health and safety risk to children in care.
POC Due Date: 03/11/2024
Plan of Correction
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Licensee will ensure all children files, with required forms, are stored in facility records by the due date: 3/11/2024.
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:Marie Rodriguez
LICENSING EVALUATOR NAME:Luis Gomez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024


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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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: DURAN, MARIA C.
FACILITY NUMBER: 214005542
VISIT DATE: 03/07/2024
NARRATIVE
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(Page 2)
At 1:30PM., PM., LPA reviewed facility files including the children’s and personnel records.
At 1:35PM., Based on observations, interview, and record review, LPA confirmed individual present without facility association.

At 2:00PM., Based on record review, observations, and interview, LPA confirmed child’s file missing from facility records.
At 2:50PM., Based on record review, interview and observations, LPA confirmed licensee operating over capacity with 12 children (6 infant-age) in care.

LPA reminded licensee to ensure staff's required proof of immunization are stored in children's files. Advisory Note: Technical Violation (LIC9102TV) was issued.

Children’s files were reviewed and included the: Identification of Emergency Information (LIC702); Notification of Parent’s Rights (LIC995); Consent for Emergency Medical Treatment (LIC627); and Immunization Records.

Licensee’s Cardiopulmonary Resuscitation/ First Aid Certification (CPR) was current, expiring: 12/2024
Licensee ‘Mandated Reporter Training’ certification (AB1207) was current, expiring: 7/2024.

Per licensee, emergency disaster drill was last drill completed on 1/26/2024, properly logged.

The required forms are posted in facility, including the Facility License; Notification of Parent’s Rights (PUB379); and Emergency Disaster Plan (LIC610A).

Per licensee, isolation of an ill child is in the playroom. Per licensee, she provides snack services for children in care. LPA advised licensee to ensure all children’s food containers brought by families are be labeled. (REFER TO 809C, FOR CONT.)

SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
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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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: DURAN, MARIA C.
FACILITY NUMBER: 214005542
VISIT DATE: 03/07/2024
NARRATIVE
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(Page 3)
Licensee was reminded that all adults 18 years and over living in the home, person who provides care and supervision to children, and staff who have contact with children, including employee and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain criminal 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with licensee and discussed Child Care Licensing Safe Sleep Web page at:https://www.cdss.ca.gov/inforesource/child-care-licesning/public-information-and-resources/safe-sleep as an additional resource. LPA informed licensee of the importance of checking for recalled infant devices on United States consumer Product Safety Commission (CPSC) website at http://www.cpsc.gov and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Licensee was informed of the www.mychildcareplan.org site is a consumer education website that helps families obtain child care by connecting to child care providers and resources and referral agencies (R&R) throughout California.

Incidental Medical Services (IMS) policy was discussed. For IMS information, see PIN 20-02-CCP. When an IMS is provided, a plan for 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- 0382 (TTY) and link to publications: 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 may 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 tool, please send them 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/inforesource/community-care-licensing/inspection-process.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
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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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: DURAN, MARIA C.
FACILITY NUMBER: 214005542
VISIT DATE: 03/07/2024
NARRATIVE
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(Page 4)
Based on today's inspection, deficiencies were cited in areas evaluated according to California Title 22, Div. 12 Chap. 3, Health and Safety, Code of Regulations and cited on 809D. Exit interview, Plans for correction, and Facility Evaluation Report was reviewed with Licensee, Maria Duran. Licensee’s signature of this form acknowledges the receipt of these documents.

Licensee was issued Type “A” violation and was advised to provide a copy of the ‘Facility Evaluation Report’ and all Type “A” Deficiencies cited, to parents and guardians of children currently enrolled in care and to parents of newly enrolled children during the next 12 months.
Signed LIC 9224, ‘Deficiency and Acknowledgment of Receipt of Licensing Reports; shall be maintained in all children's files.

Civil Penalty was issued to facility for $100.00.

During exit interview, licensee, Maria Duran confirmed that there are no registered sex offenders living in the facility, and LPA completed the RSO profile. Notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
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