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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004356
Report Date: 11/17/2021
Date Signed: 11/17/2021 10:15:05 AM

Document Has Been Signed on 11/17/2021 10:15 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:DIAS, ANA PAULAFACILITY NUMBER:
384004356
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 6TOTAL ENROLLED CHILDREN: 6CENSUS: 3DATE:
11/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Ana Paula DiasTIME COMPLETED:
10:30 AM
NARRATIVE
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Licensing Program Analyst, LPA Yee conducted an annual inspection today. The purpose of the inspection was explained. Present at the facility are licensee, Ana Paula, her nephew, Victor, and three daycare children. Current residents are Ana Paula Dias, her husband, her cousin, and their 8 years old daughter. The facility personnel summary report was reviewed with the licensee and it's current. Day-care areas (upstairs level): bedroom #3, hallway bathroom, and the deck. The remaining areas of the home are off-limit. The home is equipped with a smoke alarm, carbon monoxide detector, and fire extinguisher. The last emergency drill was conducted on September 10 and a log sheet was reviewed. The home has age-appropriate toys and equipment available for the children in care. CPR & 1st aid certificate is current until 6/2022. Mandated Reporter Training, AB1207 certificate was completed on 11/20/2021. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Sections 102417. When any IMS is provided, an updated Plan of Operation that includes 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) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, Available at: http://www.ada.gov/childqanda.htm
Safe Sleep was discussed. Lic9227 "Individual Infant Sleeping Plan" was provided.

The facility is in compliance.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jennifer Yee
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2021
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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