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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004307
Report Date: 10/06/2021
Date Signed: 10/06/2021 12:51:35 PM

Document Has Been Signed on 10/06/2021 12:51 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:HERNANDEZ, RUTHFACILITY NUMBER:
384004307
ADMINISTRATOR:HERNANDEZ, RUTHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 606-1205
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94134
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
10/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:37 AM
MET WITH:Ruth Hernandez, Mayra PadillaTIME COMPLETED:
12:45 PM
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On 10/6/2021 at 8:37A.M. Licensing Program Analyst (LPA), Luis J. Gomez met with Helper, Mayra Padilla. Purpose of the inspection was explained and is for an unannounced Annual/Random inspection. During inspection licensee arrived at the facility. Present was the Licensee and two helpers caring for six children. All children present are preschool age. 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, two- level house. Days and hours of operation are Monday – Friday, 8:00 A.M. to 5:00 P.M. Day-care Area: Lower Level: Playroom, Bathroom#1 and Backyard Area. Off-limit Area: Entire Upper Level: Kitchen, Living Room, Bedroom#2, Bedroom#3 and Bathroom#2. Lower Level: Garage and Laundry Area. Home was inspected inside and outside, with licensee for health and safety hazards.

At 8:45A.M., LPA observed the following: Day-care area 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 gate and knob covers had been installed, making all off-limit areas inaccessible. Facility has storage cabinet and hangers in entry way for children’s belongings. Playroom was equipped a child size table and several chairs for snack and activities. For nap time, licensee had stackable cots stored in the playroom. Bathroom #1 was clean with adequate supplies for the children. All fixtures were in operating condition. Facility was the proper temperature with ventilation and natural lighting. Outlets and trash bins had been covered. LPA observed detergents, cleaning compounds and other items which could pose a danger, stored in an off-limit area. Home had a functioning cell phone, smoke / carbon monoxide detector and two fully charged fire extinguisher (3A:40BC), located in the playroom.

(REFER TO 809-C FOR CONT.)

SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2021
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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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: HERNANDEZ, RUTH
FACILITY NUMBER: 384004307
VISIT DATE: 10/06/2021
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(Page 2)
At 9:10A.M., LPA inspected the Backyard Area. Backyard area was completely enclosed with tall fencing. Licensee has installed turf grass for added child safety. Accessible plants and children’s playthings appear to be free of hazards. LPA observed a shaded rest area available for the children. For water service, children’s water bottles are accessible and refilled by staff daily. Backyard does not have a swimming pool, spa, hot tub, fishpond or any other bodies of water.

At 9:20A.M., LPA reviewed the facility records. Children's records 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. Proof of liability insurance was provided during inspection. Staff records reviewed were complete, and included: Updated mandated reporter training certification (AB1207), current CPR/ first aid certification and proof of required immunization.

Facility is conducting and logging required emergency disaster drills. Last disaster drill was completed on 9/13/2021. Children's Roster (LIC 9040) was properly updated. Licensee and helpers, CPR/ 1st aid certifications are current and expires, 9/27/2022. LPA observed required forms visibly posted in the playroom. Posted forms including the Facility License, Emergency Disaster Plan, COVID-19 Guidance and the Parent's Rights. Licensee stated families provides all day snacks and meals for the day-care children. LPA reminded licensee to label all children food containers. Per licensee, 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. (REFER TO 809-C, FOR CONT.)
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
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: HERNANDEZ, RUTH
FACILITY NUMBER: 384004307
VISIT DATE: 10/06/2021
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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.

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, Ruth Hernandez. 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: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
LIC809 (FAS) - (06/04)
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