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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384002612
Report Date: 08/20/2024
Date Signed: 08/20/2024 10:42:37 AM

Document Has Been Signed on 08/20/2024 10:42 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 CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:RIVAS, SAMARYFACILITY NUMBER:
384002612
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 5CENSUS: 5DATE:
08/20/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:35 AM
MET WITH:Samary RivasTIME VISIT/
INSPECTION COMPLETED:
10:50 AM
NARRATIVE
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On August 20, 2024 at approximately 8:35am, Licensing Program Analyst (LPA) Catrina Quimbo, conducted an unannounced, annual inspection. LPA met with licensee, Samary Rivas, and explained the purpose of the visit. Upon LPA's arrival, 3 infants were present.

Licensee lives in the home with their spouse, father, mother, and two minor children. All adults living in the home have fingerprint clearance on file. Hours of operation are Monday through Friday 8:00am to 4:30pm. LPA inspected day care areas for health and safety hazards.

At approximately 8:50am, additional infant arrived to the home (4 infants present). The home is a multi-level home that consists of three levels. The DAY CARE AREAS are located on the second level of the home only that includes the living room/kitchen area (main play room), bathroom #1, and outdoor/patio area. The OFF LIMIT AREAS are the garage (ground level), family room (second level), dining area (second level), and entire third level of the home. There are stairs in the home that include a child safety gate and/or a closed door.

Home is in good repair with proper temperature and ventilation. Home includes toys and materials that are in good condition. Flooring in home includes carpets that is in good condition, free of stains. LPA did not observe any accessible electrical outlets in the day care area.

At approximately 9:00am, preschool child arrived to facility (1 preschool age, 4 infants). Home is equipped with a fully charged fire extinguisher and multiple smoke and carbon monoxide detectors. LPA tested carbon monoxide detector in living room, which was observed to be working. Garbage bin in kitchen was observed to be made inaccessible to children.

Restroom is not currently utilized for children as all children present are in diapers. LPA observed restroom to be clean and in working condition. LPA observed children's diapers to be properly labeled with each child's individual names.
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SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2024
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 08/20/2024 10:42 AM - It Cannot Be Edited


Created By: Catrina Quimbo On 08/20/2024 at 09:35 AM
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: RIVAS, SAMARY
FACILITY NUMBER: 384002612

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(b)(1)
Staffing Ratio and Capacity
(b) For a Small Family Child Care Home, the maximum number of children for whom care may be provided at any one time, including children under age 10 who reside at the licensee's home, shall be one of the following: (1) Four infants; or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above. 5 children, 4 infants (under 24 months) and 1 preschool age (over 24 months) were present during LPA's visit, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/21/2024
Plan of Correction
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LPA discussed ratio and capacity with licensee. LPA provided printed copy of family child care home ratio worksheet. Licensee stated part time children stagger schedules so they do not overlap. LPA to conduct a follow up visit.
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:Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/20/2024 10:42 AM - It Cannot Be Edited


Created By: Catrina Quimbo On 08/20/2024 at 09:35 AM
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: RIVAS, SAMARY
FACILITY NUMBER: 384002612

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above. Sleeping logs were not maintained for any infant present, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
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LPA previously provided licensee with a sample of a sleeping log/chart for a napping infant. LPA reminded licensee all infants sleeping while in licensee's care must have a sleeping log maintained. Sleeping log must document every 15 minutes of when the infant is checked on while sleeping. A follow up visit to be conducted.
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:Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024


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: RIVAS, SAMARY
FACILITY NUMBER: 384002612
VISIT DATE: 08/20/2024
NARRATIVE
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Outdoor/patio area (entrance area) is not currently in use. LPA did not observe any pools, spas or bodies of water on site.

All children enrolled currently sleep on foldable, floor mats. No cribs are currently utilized. Licensee does not maintain a sleeping log for napping infants. LPA reminded licensee sleeping logs must be documented for every infant napping in licensee's care.

LPA discussed the safe sleep regulations with licensee and
discussed the Child Care Licensing Safe Sleep webpage at
https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed licensee 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.

LPA reviewed all enrolled children's files. Children's files are complete with infant individual sleeping plans and emergency contact information.

Licensee does not currently provide a food service at this time. Children's families provide food daily that is stored in their individual lunch boxes. Licensee has licensing documents posted and available for review. Licensee's CPR/First Aid certification is current and will expire 02/2026. Licensee's Mandated Reporter certification expired as of 03/2024. LPA reminded licensee Mandated Reporter training must be renewed every two years by all staff working with children.

Licensee was reminded, as of September 1, 2016, all Staff and Volunteers must provide proof of immunization against pertussis, measles, and influenza, or qualifies for an exemption, pursuant to Health and Safety code 1596.7995 and 1597.622.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. 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 are available at: https://www.ada.gov/resources/child-carecenters/
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SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
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: RIVAS, SAMARY
FACILITY NUMBER: 384002612
VISIT DATE: 08/20/2024
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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 CARE tools, please send email inquiries 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/inforesources/community-care-licensing/inspection-process.

Licensee was reminded that all adults 18 and over living or working in the home, 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.

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

During the exit interview, the licensee, Samary Rivas, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

During LPA's visit, licensee was operating over capacity with 4 infants and 1 preschool age child present. Per licensee, preschool age child staggers schedule with part time children.

Licensee was issued one Type A citation for operating over capacity and one Type B citation for not maintaining sleeping logs for napping infants. See 809D for more information. LIC9924 was given to licensee. A plan of correction was discussed. Appeal Rights were provided to licensee during visit as well as a copy of this report.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee, Samary Rivas.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
LIC809 (FAS) - (06/04)
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