384004463-9-27-2023-05-CC-LGOZ-CW3PY7-20230927114325

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 384004463
Report Date: 09/27/2023
Date Signed: 09/27/2023 11:43:43 AM

Document Has Been Signed on 09/27/2023 11:43 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:	RODRIGUEZ, ANA SARA		FACILITY NUMBER:	384004463
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 3	DATE:	09/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Ana Sara Rodriguez		TIME COMPLETED:	11:50 PM

NARRATIVE

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On 9/27/2023 at 9:00AM., Licensing Program Analysts (LPA), Luis J. Gomez met with Licensee, Ana Sara Rodriguez. Purpose of the inspection was explained and was for an Unannounced; Annual Random. Present was the licensee and one adult, caring for 3 children (2 infant age, 1 preschool age). Licensee’s home is a 2 bedroom, 1 bathroom, 1 level unit. Days and hours of operation are Monday- Friday 8:00AM- 5:00PM. Day-care areas are: Bedroom #1; Bathroom #1; and Living Room (Playroom). Off-Limit areas are: Kitchen Area (Pass through only) and Bedroom #2. LPA inspected home with licensee for health and safety hazards.

At 9:05PM., the following was observed: Facility was clean with age-appropriate playthings available for the children. Floors/ground surfaces was clear of obstructions. Accessible children’s furniture, toys and books inspected were in good repair.

At 9:15AM., Based on observations, LPA confirmed dry paint bucket/ motor oil container in the pass-through area (Kitchen). Hazardous items were removed from kitchen area during inspection.

Playroom has child sized tables and chairs for seated activities. For napping services, LPA observed playpen located in bedroom #1.

At 9:30AM., Based on observations, LPA confirmed furniture placement hindering access to infant play pen in bedroom #1. Advisory Note: Technical Violation (LIC9102TV) was issued.

Play pen inspected had tight-fitting sheet and properly sized mattress. The off-limit areas have been made inaccessible with child safety gates. Bathroom #1 had with supplies for hand washing. Facility was the proper temperature with ventilation. Home had functioning telephone service; smoke/ carbon monoxide combination detector; and fire extinguisher: 2A:10:BC, located in kitchen. (REFER TO 809C, FOR CONT)

SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

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 09/27/2023 11:43 AM - It Cannot Be Edited

Created By: Luis Gomez On 09/27/2023 at 10:05 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: RODRIGUEZ, ANA SARA	FACILITY NUMBER: 384004463
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(b)

Operation of A Family Child Care Home

(b) The home shall be kept clean and orderly, with heating and ventilation for safety and comfort. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	At 9:15AM., Based on observations, LPA confirmed dry paint bucket/ motor oil container in the pass-through area (Kitchen). Items were removed during inspection. This poses a potential health and safety risk to children care.
	POC Due Date: 09/28/2023
	Plan of Correction
1 2 3 4	Licensee removed hazardous items from kitchen area during inspection. Deficiency has been cleared.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Luis Gomez

LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

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: RODRIGUEZ, ANA SARA	FACILITY NUMBER: 384004463
	VISIT DATE: 09/27/2023

NARRATIVE

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(Page 2)
Facility does not have any pools, fishponds, or other bodies of water.

At 9:45AM, LPA reviewed facility, and children’s records.

Children’s files were reviewed and included the: Notification of Parent's Rights (LIC995); Identification of Emergency Information (LIC702); Individual Infant Sleeping Plans (LIC9227); Immunization Record; and Consent for Medical Treatment (LIC627).

LPA advised licensee maintaining required infant napping logs, documenting each 15- minute review.

Licensee's Cardiopulmonary Resuscitation (CPR)/ First Aid certification was current, expiring: 4/2025.
LPA reminded licensee to renew required 'Mandated Reporter Training' (AB1207) certification every two years. Advisory Note: Technical Violation (AB1207) was issued.

Licensee is conducting and emergency disaster drills every six months, with last drill completed on: 4/10/2023, properly logged.

During inspection, maintenance professional arrived to repair light fixtures. Incident report form, LIC624b was submitted during inspection.

Required forms are posted in entry way, including the Childcare License; Notification of Parent’s Rights (PUB379); Emergency Disaster Plan (LIC610A).

Per licensee, isolation of an ill children in care, is in playroom.

Per licensee, she provides food service for children in care. LPA advised licensee to ensure all children’s food containers brought by families are be labeled. Per licensee, home does not have any firearms.

Licensee was reminded that all adults 18 years and over living in the home, person who provides care and supervision to children, and staff who have contact with children, including employee and volunteers, except as specified in Health and Safety Code section 1596.871, 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 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. (REFER TO 809C, FOR CONT.)

SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

LIC809 (FAS) - (06/04)

Page: 5 of 6

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: RODRIGUEZ, ANA SARA	FACILITY NUMBER: 384004463
	VISIT DATE: 09/27/2023

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(Page 3)
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.

Licensee was informed of the www.mychildcareplan.org site is a consumer education website that helps families obtain child care by connecting to child care providers and resources and referral agencies (R&R) throughout California.

Incidental Medical Services (IMS) policy was discussed. For IMS information, see PIN 20-02-CCP. When an IMS is provided, a plan for 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- 0382 (TTY) and link to publications: Commonly asked questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

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 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, deficiencies were observed in areas evaluated according to California Title 22, Div. 12 Chap. 3 Health and Safety Code of Regulations and cited on 809D. LPA conducted exit interview, appeal rights, report was reviewed with licensee, Ana Sara Rodriguez. Licensee’s signature of this form acknowledges receipt of these documents.

During exit interview, licensee, Ana Sara Rodriguez confirmed that there are no registered sex offenders living in the facility, and LPA completed the RSO profile. Notice of site visit was given and must remain posted for 30 days.

SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

LIC809 (FAS) - (06/04)

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