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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214005645
Report Date: 07/26/2023
Date Signed: 07/26/2023 11:25:42 AM


Document Has Been Signed on 07/26/2023 11:25 AM - 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 CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:PALENCIA, DELMI S.FACILITY NUMBER:
214005645
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 0DATE:
07/26/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Delmi PalenciaTIME COMPLETED:
11:40 AM
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On July 26, 2023, at approximately 9:15AM, Licensing Program Analyst (LPA) Maria Olguin-Leon conducted an announced, pre-licensing inspection. LPA met with applicant, Delmi Palencia and explained the purpose of the inspection. Present today was applicant. Applicant lives in home with 3 other adults.

Applicant submitted family childcare home application to department on June 1, 2023. Applicant plans to operate Monday to Friday from 7:30am to 4:30pm. Applicant plans to care for children ages 2 months to 10 years old.

With applicant, LPA inspected apartment for health and safety hazards. Applicant rents apartment that consists of a living room, dining room, kitchen, 2 bedrooms and 1 bathroom. The DAY CARE AREAS are the living room (playroom) and bedroom #2 (napping only), and bathroom. The OFF-LIMIT AREAS bedroom #1, kitchen, dining room. Applicant was notified any off-limit areas are not to be used as a day care area without prior approval from department.

LPA observed the following: Home was clean and orderly. Playroom area (living room) has bookcase, toy storage cubbies, changing table, child size furnishing, playpen, sleeping mats and age-appropriate toys. Per applicant, changing table will be disinfected after each use. Living room is properly barricaded with child proof gates. Kitchen and dining room are barricaded with childproof gates.

Home has ventilation and lighting throughout. Per applicant, off-limit areas will remain locked during operating hours with child proof latches. or closed doors. All detergents, cleaning compounds, medications and other items which could pose a danger are stored inaccessible to children behind child safety locked cabinets and/or located in off limit areas. Per applicants, there are no weapons or firearms in the home.

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SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Maria Olguin-LeonTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2023
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 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: PALENCIA, DELMI S.
FACILITY NUMBER: 214005645
VISIT DATE: 07/26/2023
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Home is equipped with a working smoke and carbon monoxide detectors and a fully charged fire extinguisher. LPA observed a first aid kit fully stocked with necessary supplies. Applicant uses a designated cell phone and is aware the cell phone must stay within the home during the day care hours. Isolation area for sick children will be in living room away from other children and where applicant can supervise all children in care. For discipline applicant will use redirection and talk to children about behavior.

LPA reviewed the LIC311D, Records to Keep in Your Family Child Care Home, children’s forms/ records, facility forms, and information to be posted. Applicant’s CPR/First Aid certification is current and will expire 05/2025. Applicants Mandated Reporter training certificates (AB1207) is current that will expire 10/2024.

LPA and applicant discussed licensing regulations and the capacity requirements. Any children under 10 years of age that live in the home, will be counted in overall capacity. Applicant plans to have children bring their own meals. LPA discussed sanitation and allergies with applicants. LPA reminded Applicant to label all food brought from home.

Applicant understands the required emergency disaster drills are to be conducted and documented at least once every six months. Applicant understands that the use of baby walkers, bouncers, jumpers, and similar items are not to be used for children in care. Smoking is prohibited inside a Family Childcare Home.

Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 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.



The applicant provided proof of control of property.

Cont. page 3...
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Maria Olguin-LeonTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: PALENCIA, DELMI S.
FACILITY NUMBER: 214005645
VISIT DATE: 07/26/2023
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Because the applicant rents/leases the home, proof of landlord notification is required. The LPA observed the Property Owner/Landlord Notification form (LIC9151) that the applicant confirms was provided to the property owner/landlord.

The applicant has not obtained a signed Property Owner/Landlord Consent form (LIC9149). Without this consent, the applicant understands that, once licensed, they can operate with a maximum capacity of 6 [or 12] children. If property owner/landlord consent is obtained in the future, the applicant is advised that a new Application for a Family Child Care Home License (LIC 279) must be submitted with a change of capacity fee of $25, to increase the capacity and provide care to 8 [or 14] children. PIN 22-05-CCP Page Seven

This facility plans to provide Incidental Medical Services – IMS. For IMS information, see PIN 22-02-CCP. 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) or (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

LPA reviewed with applicant the LIC 311D, Forms/Records to Keep in Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. Entrance Checklist was provided to the applicant.

LPA discussed the safe sleep regulations with applicant 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 [applicant, licensee, or facility representative] 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.

Cont. page 4...
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Maria Olguin-LeonTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: PALENCIA, DELMI S.
FACILITY NUMBER: 214005645
VISIT DATE: 07/26/2023
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On this date, 06/02/2023, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication

Applicant was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain childcare by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Prior to recommended licensure, following must be completed:

Fingerprint clearance for all adults living in home.

Exit interview conducted and report was reviewed with the applicant, Delmi Palencia.

SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Maria Olguin-LeonTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4