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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343624224
Report Date: 06/10/2022
Date Signed: 06/10/2022 03:26:52 PM

Document Has Been Signed on 06/10/2022 03:26 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:HERNANDEZ, KARENFACILITY NUMBER:
343624224
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
06/10/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Karen HernandezTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Kelly Ferrara met with Applicant Karen Hernandez to conduct a Pre-Licensing inspection. Applicant was previously licensed with the San Bruno Regional Office, facility number 414004716. LPA toured the applicant's two story, four bedroom and a loft, three bathroom home. All adults currently living or working in the home have received a criminal background clearance and are associated to the facility. 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, 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.

Off-limit areas will consist of: Dining room, kitchen, master bedroom, laundry room, and garage. Applicant understands that children may never enter the off-limit areas. Applicant acknowledges she is required to notify licensing prior to making changes to off-limit areas so that they may be inspected for safety. LPA observed a functioning smoke and carbon monoxide detector and 1A-10-BC fire extinguisher. LPA advised that a 2A-10-BC fire extinguisher is needed. Hazardous cleaning products and chemicals, knives, and medications are all stored inaccessible to children. Applicant understands that poisons must be locked. The backyard is fenced and LPA advised applicant that in areas that are not fenced, 100% supervision must be maintained at all times. Applicant stated she does not have any firearms and there were no bodies of water.
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. Applicant has a current pediatric CPR/1st aide certificate and has completed the preventative health and safety course. Applicant currently needs an updated TB test. Applicant has completed the Mandated Reporter training and has provided proof of immunizations. Applicant was reminded that the CPR/1st aide and Mandated Reporter certificates must be updated every two years. LPA obtained proof that the applicant lives in the home. Applicant understands that if she does not have liability insurance, she will have parents fill out an affidavit.
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Kelly Ferrara
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2022
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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: HERNANDEZ, KAREN
FACILITY NUMBER: 343624224
VISIT DATE: 06/10/2022
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LPA reviewed current COVID-19 guidelines, postings, and protocols. LPA reviewed Type A and Type B citations, Zero Tolerance, and Civil Penalties. LPA reviewed open door policy, supervision, fire drills, children’s personal rights, reporting requirements, and the smoking prohibition with the applicant. A current roster of children enrolled must be available and maintained for a period of three years, even after children are no longer in care. LPA went over requirements for an assistant. LPA reminded applicant that annual fees must be paid promptly and by the due date or late fees will be assessed. LPA advised applicant that she has the option to put her home on Inactive Status at any time for up to a year while continuing to pay fees.

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 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.

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.

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 platform. 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. CCLD.CA.GOV

SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Kelly Ferrara
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: HERNANDEZ, KAREN
FACILITY NUMBER: 343624224
VISIT DATE: 06/10/2022
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Applicant was advised a Small Family Child Care Home has a capacity of 6 children with no more than 3 infants, or 4 infants only, or up to 8 children with no more than 2 infants, 1 child in Transitional Kindergarten or above and 1 child at least age 6. Infants are children under the age of 2.

A provisional license will be provided once applicant submits proof of purchase of a 2A-10-BC fire extinguisher for the home.

Applicant will receive a regular license once proof of a current TB test has been received.

Exit interview conducted and report was reviewed with the applicant.
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Kelly Ferrara
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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