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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384001899
Report Date: 01/19/2024
Date Signed: 01/19/2024 03:49:49 PM

Document Has Been Signed on 01/19/2024 03:49 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:ZELAYA, IVANIA A.FACILITY NUMBER:
384001899
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 3DATE:
01/19/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Ivania ZelayaTIME COMPLETED:
03:55 PM
NARRATIVE
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On 1/19/2024 at 1:35PM., Licensing Program Analysts (LPA), Luis J. Gomez met with Licensee, Ivania Zelaya. Purpose of the inspection was explained and was for an Unannounced; Annual Random. Present was the licensee and helper caring for 3 children (2 Infant-age, 1 Preschool- age). Licensee’s home is a one bedroom, one bathroom, one level unit. The days and hours of operation are: Monday- Friday: 9:00am- 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 licensee’s home for health and safety hazards.

At 1:40PM., the following was observed: Facility was clean, orderly, with age-appropriate playthings available for the children. Furniture, toys, and books inspected were in good repair. Cubbies are available for storage of children’s belongings. Playroom has child- sized tables and chairs for seated activities. For napping services, LPA observed infant cribs, equipped with tight-fitting sheets. Facility has foldable mats, made from a cleanable material. Crib/ plan pen was observed for each infant in care. Bathroom #1 was maintained clean with supplies for hand washing. Facility was a comfortable temperature, with ventilation and lighting. The off-limit areas have been made inaccessible. Home had functioning telephone service; smoke/ carbon monoxide combination detector; and fire extinguisher: 2A:10:BC.

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: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2024
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 01/19/2024 03:49 PM - It Cannot Be Edited


Created By: Luis Gomez On 01/19/2024 at 02:29 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: ZELAYA, IVANIA A.
FACILITY NUMBER: 384001899

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 2:20PM., Based on record review, observations and interview, LPA confirmed licensee’s helper, S1, present without proper criminal record clearance on file. This poses an immediate health and safety risk to children in care.
POC Due Date: 01/20/2024
Plan of Correction
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Licensee will ensure helper/ occupant, S1, receives criminal record clearance prior to due date: 1/20/2023. Proof of correction will be submitted to department via email.
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: 01/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2024


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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: ZELAYA, IVANIA A.
FACILITY NUMBER: 384001899
VISIT DATE: 01/19/2024
NARRATIVE
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(Page 2)
At 2:10PM., LPA reviewed facility records including the children’s files and personnel files. Children’s files were reviewed and included the: Consent for Medical Treatment (LIC627); Affidavit Regarding Liability Insurance (LIC282); and Notification of Parent’s Rights (LIC995).

At 2:20PM., Based on record review, observations and interview, LPA confirmed licensee’s helper, S1, present without proper criminal record clearance on file.

At 2:25PM., Based on record review and interview, LPA confirmed licensee is not documenting infant napping conditions every 15 minutes. Advisory Note: Technical Violation (LIC9102TV).

Licensee’s Cardiopulmonary Resuscitation/ First Aid Certification was current, expiring: 3/2025.
Licensee’s required ‘Mandated Reporter Training’ (AB1207) was current, expiring: 6/2024.

Licensee to conduct emergency disaster drill every 6 months, with last one done on 12/10/2023, properly logged.

The required postings 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 food service for children in care. LPA advised licensee to ensure all children’s food containers brought by families are be labeled. Per licensee, home does not have any firearms. (REFER TO 809C, FOR CONT.)

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

DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024
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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: ZELAYA, IVANIA A.
FACILITY NUMBER: 384001899
VISIT DATE: 01/19/2024
NARRATIVE
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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.
(REFER TO LIC809c, FOR CONT.)
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024
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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: ZELAYA, IVANIA A.
FACILITY NUMBER: 384001899
VISIT DATE: 01/19/2024
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(Page 4)
Based on today's inspection, deficiencies were observed in areas evaluated according to California Title 22, Div. 12 Chap. 3 Health and Safety Code of Regulations and cited on 809D. Exit interview, appeal rights, plan of correction and report was reviewed with Licensee, Ivania Zelaya. Licensee’s signature of this form acknowledges the receipt of these documents.

Type “A” violation was issued today. Director was advised to provide a copy of the 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. A signed and dated LIC 9224 (Deficiency and Acknowledgment of Receipt of Licensing Reports) shall be maintained in all children's files.

Civil Penalty of $100.00 was issued during inspection.

During exit interview, licensee, Ivania Zelaya 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: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024
LIC809 (FAS) - (06/04)
Page: 6 of 7