<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384001899
Report Date: 05/23/2022
Date Signed: 05/23/2022 11:05:09 AM

Document Has Been Signed on 05/23/2022 11:05 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:ZELAYA, IVANIA A.FACILITY NUMBER:
384001899
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 2DATE:
05/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Ivania ZelayaTIME COMPLETED:
11:15 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On May 23, 2022 at 8:40AM., Licensing Program Analyst (LPA), Luis J. Gomez met with Licensee, Ivania Zelaya. Purpose of the inspection was explained and was for an unannounced, annual/random inspection. Present in home was the licensee. During inspection, two families arrived to the facility. Both children present were preschool age. Licensee’s home is a one bedroom, one bathroom, one level unit. Hours of Operation are: Monday- Friday: 8:00am- 5:00pm. Daycare areas are: Living Room (Playroom), Hallway and Bathroom #1 Off Limit areas are: Kitchen, Bedroom #1 and Side Room (Next to Living Room Area). LPA inspected entire home with licensee for health and safety hazards.

At 8:50AM., the following was observed: Home was clean and orderly with age appropriate materials available for the children. Furniture and playthings inspected were in good repair. Playroom had child size table with chairs for snack and activities. Stored in playroom were the children’s mats and one infant crib. For children belongings, storage unit had been installed in facility hallway, next to the diaper-changing table; Per licensee, table is disinfected after each use. Bathroom #1 was observed clean with adequate supplies for hand-washing. Bathroom fixtures tested were in operating condition. The off-limit areas had been made inaccessible with child safety gates and protective knobs. Windows in playroom had removable safety gates installed for added safety. Outlets and trash bins had been properly covered. Cleaning detergents, compounds, wipes, spray bottles and items which could pose a danger, were stored inaccessible to children. Facility was the proper temperature with adequate ventilation and lighting. Home had functioning cell phone, smoke detector, carbon monoxide detector and one, fully charged fire extinguisher (2A:10BC). Home did not have any swimming pools, spas, hot tubs, fishponds or other bodies of water.(REFER TO 809C FOR CONT.)
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2022
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 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: ZELAYA, IVANIA A.
FACILITY NUMBER: 384001899
VISIT DATE: 05/23/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(Page 2)

At 9:25AM., LPA reviewed the facility and children’s records. Children's records were reviewed and included the: Identification of Emergency Information (LIC700), Consent for Medical Treatment (LIC627), Notification of Additional Children in Care (LIC9150) and Immunization Records.

LPA reminded licensee to ensure signed the Notification of Parent's Rights forms (LIC995A) are stored in the children's files.

Licensee’s Cardiopulmonary Resuscitation (CPR)/ First Aid Certification was current, expiring on 3/2023. Licensee's mandated reporter training certification (AB1207) was current, expiring 6/7/2022.

Facility is conducting and documenting the required emergency disaster drills. Last drill competed was on: 3/10/2022.

LPA observed posting, including: Facility License, Notification of Parent’s Rights and Emergency Disaster Plan (LIC610A) properly posted in facility. Children's Roster (LIC500) was reviewed during inspection and was current.

Per licensees, no children in care require incidental medical services (IMS) at this time.

Isolation of ill child in care will take place in facility hallway. Per licensees, facility provides all lunch and snack for children in care. LPA asked licensee to ensure all children’s food containers brought to facility by families are properly labelled. Per licensee, home does not have any no guns or weapons.

Licensee was reminded that all adults 18 years and over, living or working in the home, including employee and volunteers, 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 up to $500.00 maximum per day/ per person will be assessed if this regulation is violated.

(REFER TO 809C, FOR CONT.)

SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022
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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: ZELAYA, IVANIA A.
FACILITY NUMBER: 384001899
VISIT DATE: 05/23/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(Page 3)

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.

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 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.

Based on today's inspection, no deficiencies were observed in areas evaluated, according to California Title 22, Health and Safety Code of Regulations. Exit interview was conducted with Licensee, Ivania Zelaya and signature of this form acknowledges receipt of these documents.



Notice of Site Visit was provided and must be posted for 30 days.

This report must be available in the facility for public review. Licensee was advised any additional questions to call Office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3