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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384002430
Report Date: 03/23/2022
Date Signed: 03/23/2022 04:05:36 PM

Document Has Been Signed on 03/23/2022 04:05 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:MOTINO, ROSALBAFACILITY NUMBER:
384002430
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 4DATE:
03/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Rosalba MotinoTIME COMPLETED:
04:15 PM
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 3/23/2022 at 12:55P.M., Licensing Program Analyst (LPA), Luis J. Gomez met with Licensee, Rosalba Motino. Purpose of the inspection was explained and is for an unannounced, Annual/ Random inspection. Present was the licensee caring for 4 children. All children present were preschool age. Per licensee, adult/ family member in off-limit area is visiting. Licensee’s home is a 4 bedroom, 1 bathroom, 1 level apartment. Hours of Operation are: Monday- Friday: 8:00am- 5:00pm. Day-care areas are: Living room (Playroom), Bathroom #1, and Hallway. Off Limit areas are: Bedrooms #1, #2, #3, #4, Kitchen (Pass through only), and Storage area. LPA inspected entire home with licensee for health and safety hazards

At 1:00P.M., the following was observed: Home was maintained orderly with all age appropriate playthings available for the children. Accessible furniture inspected was in good repair. Licensee installed carpeting on floor for added safety. LPA observed individual storage drawers located next to facility playroom for added storage. Diaper changing table is located in hallway. Per licensee, table is disinfected after each use. For napping services, infant cribs and cots are stored in playroom. Per licensee, napping blankets are washed weekly. Accessible outlets and trash bins had been covered. Bathroom #1 was observed clean with adequate supplies. Bathroom fixtures were in proper operating condition. Off-limit areas and staircase have been made inaccessible with child safety gates. Cleaning detergents, compounds, wipes, spray bottles and other items, which could pose a danger, are stored in the off-limits areas. Facility was the proper temperature with adequate ventilation and lighting. Home had a functioning telephone service, smoke/ carbon monoxide detector combo and fully charged fire extinguisher (3A:40BC), located in hallway. (REFER TO 809C FOR CONT.)
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2022
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: MOTINO, ROSALBA
FACILITY NUMBER: 384002430
VISIT DATE: 03/23/2022
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 1:45P.M., LPA reviewed facility and children’s records. Children's records were reviewed and included: (LIC627) Consent for Medical Treatment, (LIC995A) Notification of Parent's Rights and Updated Immunization Records. LPA reminded licensee to ensure all children's files contain signed Identification of Emergency Information (LIC 700) and Liability Affidavit.

Licensee is conducting Emergency Disaster Drills monthly. Facility's last drill was conducted on 3/11/2022 and was properly documented.

Licensee's cardiopulmonary resuscitation / first aid certification was current, expiring on: 7/10/2023. Licensee's mandated reporter training certification was current, expiring on 1/7/2023. LPA reminded license to update required children's roster.

LPA reminded licensee to ensure all forms are properly posted in visible location. Required form include the: Facility License, Notification of Parent’s Rights and Emergency Disaster Plan (LIC610A). Licensee updated children's roster during inspection.

Per licensee, no children in care requiring IMS Incidental Medical Services. Per licensee, facility provides daily snack for children in care. LPA asked licensee to ensure all children’s food containers brought to facility by families are properly labeled. 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.

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. (REFER TO 809C, FOR CONT.)

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

DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
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: MOTINO, ROSALBA
FACILITY NUMBER: 384002430
VISIT DATE: 03/23/2022
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)

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 the areas evaluated, according to California Title 22, Health and Safety Code of Regulations. Exit interview and facility evaluation report was reviewed with Rosalba Motino, and her signature acknowledges receipt of these documents.



Notice of Site Visit was provided and must remain 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: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3