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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004277
Report Date: 09/24/2021
Date Signed: 09/24/2021 12:19:49 PM

Document Has Been Signed on 09/24/2021 12:19 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:WILLIAMS, TESSA MARIEFACILITY NUMBER:
384004277
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
09/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Tessa Williams, Norma Bonilla TIME COMPLETED:
12:20 PM
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On 9/24/2021 at 8:40A.M. Licensing Program Analyst (LPA), Luis J. Gomez met with Helper, Norma Bonilla. Purpose of the inspection was explained and is for an unannounced Annual/Random inspection. During inspection licensee arrived to the facility. Present was the Licensee and one helper caring for four child (3- Preschool age and 1-Infant Age). Per licensee, Infant age child present is her daughter. All adults have their criminal record clearances on file. Licensee is within the capacity limits of the license on this day. Licensee home is a two bedroom, two bathroom, 2- level Loft. Days and hours of operation are Monday – Friday, 8:30 A.M. to 5:30 P.M. Day-care Area: (Lower Level) Living Room (Playroom), Bathroom #1, Bedroom #1 and Kitchen Area (Pass through only). Off-limit Area: (Upper Level) Bedroom #2 and Bathroom #2. Home was inspected with the licensee for health and safety hazards.

At 8:42A.M., LPA observed the following: Day-care was clean, orderly with a variety of age appropriate books, blocks and toys for the children. All furniture and playthings inspected were in good repair. Safety gates and locks have been installed on accessible cabinets in bathroom #1. At 8:45A.M., LPA observed two baby bouncers in the day-care area. Technical assistance TA9102 was issued during inspection. All sharp corners have been covered. The storage cabinet for children's belongings located in the playroom. Licensee had a size table and several chairs for snack and activities. For nap time, LPA observed padded cleanable mats stored in bedroom #1. Bathroom #1 was clean with adequate supplies for the children. All fixtures were in operating condition. Facility was the proper temperature with adequate ventilation and natural lighting. Outlets and trash bins had been covered. The detergents, cleaning compounds, medications and other items which could pose a danger were being stored inaccessible to the day-care children. Home had a functioning cell phone, smoke / carbon monoxide detector and a fully charged fire extinguisher (3A:40BC), located in the kitchen.

At 10:00A.M., LPA reviewed the facility records. Children's files reviewed were complete, and included: Proof of Immunization, (LIC 627) Consent for Medical Treatment, (LIC700) Identification of Emergency Information and (995A) Notice of Parent's Rights. (REFER TO 809-C FOR CONT.)

SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2021
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 4
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: WILLIAMS, TESSA MARIE
FACILITY NUMBER: 384004277
VISIT DATE: 09/24/2021
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Licensee is conducting and logging required emergency disaster drill. Last drill was completed on 4/28/2021. Children's Roster (LIC 9040) was updated during inspection. Licensee and helpers, CPR/ 1st aid certification was current and expires, 2/2022. Staff records have updated mandated reporter training certification, proof of immunization on file. LPA observed all required forms visibly posted, including the Facility License, Emergency Disaster Plan, COVID-19 Guidance and the Parent's Rights. Licensee stated there are no guns or weapons in the home.

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 Webpage 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.

Incidental Medical Services (IMS) 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 Americans with Disabilities Act (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: www.ada.gov/childqanda.htm.

(REFER TO 809-C FOR CONT,

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

DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021
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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: WILLIAMS, TESSA MARIE
FACILITY NUMBER: 384004277
VISIT DATE: 09/24/2021
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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 the Title 22 Division 12 Ca. Code of Regulations. Exit interview was conducted and report was reviewed by the Licensee, Tessa Williams. Her signature of this form acknowledges receipt of these documents. Notice of Site Visit was given and must be posted for 30 days.



>This report and rights to comment and appeal were discussed with licensee. 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: www.ccld.ca.gov
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021
LIC809 (FAS) - (06/04)
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