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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004553
Report Date: 06/20/2024
Date Signed: 06/20/2024 03:51:00 PM

Document Has Been Signed on 06/20/2024 03:51 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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:AMADOR,YOLANDA I.FACILITY NUMBER:
384004553
ADMINISTRATOR/
DIRECTOR:		AMADOR,YOLANDA I.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(917) 680-0097
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94112
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
06/20/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:55 PM
MET WITH:Laine Ibarra, Juan Valderramos TIME VISIT/
INSPECTION COMPLETED:
04:05 PM
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On 6/20/2024 at 12:55PM., Licensing Program Analyst (LPA), Luis Gomez met with Assistant, Laine Ibarra. The purpose of today’s visit was explained and was for an unannounced, annual random inspection. Present were two assistant caring for 9 children. All children presents were preschool-age. All adults have criminal record clearances on file. Licensee’s son, Juan Valderramos arrived during inspection. Licensee’s son stated his mother is not current available. Days and hours of operations are Monday- Friday, 7:30AM.- 5:30PM. Childcare is located on the ground level of the home. The areas of the home designated for childcare are Ground Level: Kitchenette; Bedroom #1 (Playroom #1); Bedroom #2 (Playroom #2); Bathroom #1, #2; and Backyard Area. Areas of the home designated as off-limits: Ground Level: Garage; Entire Upper Level: Bedroom #3, #4, #5; Bathrooms #3, #4; Kitchen; and Living Room. LPA inspected home inside and outside for health and safety hazards.

At 1:00PM., the following was observed: Facility was clean, neat, with age-appropriate playthings available for the children. The floors and ground surfaces were clear of obstructions. Accessible furniture, books, and supplies inspected were in like-new condition. Facility has cubbies and hangers for storage of children’s belongings. Playroom has seat area in kitchenette, with furniture scaled to the appropriate size. Accessible cabinets in kitchen have safety locks installed.

For napping services, LPA observed several stackable cots stored in facility. Per Licensee’s son, napping supplies are washed bi-weekly. Bathrooms #1, #2 were observed clean with several portable potty chairs and supplies for hand washing.

LPA reminded facility to keep all medications inaccessible to children. Advisory Note: Technical Violation (LIC9102TV) was issued.

Home was a comfortable temperature with ventilation and lighting. The off-limit areas of the home had been made inaccessible. Home had telephone service; functioning carbon monoxide/ smoke combination detector; and fire extinguisher: 2A:10BC located in the kitchen. (REFER TO 809C, FOR CONT.)

SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2024
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 5
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: AMADOR,YOLANDA I.
FACILITY NUMBER: 384004553
VISIT DATE: 06/20/2024
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(PAGE 2)
At 1:25PM. LPA inspected Backyard Area. Areas was completely enclosed, with turf padded installed around structure for added safety. Playthings inspected were in good repair. Home does not have any pools, fishpond, jacuzzi, or other bodies of water. LPA reviewed shed during inspection.

At 1:45PM., LPA reviewed facility records including the children and personnel files. Personnel Files reviewed contained the: Notice of Employee Rights; Acknowledgement to Report Suspected Child Abuse (LIC9108); Mandated Reporter Training (AB1207); and Personnel Record (LIC501).

The children’s files were reviewed and included the: Notification of Parent’s Rights (LIC995); Consent for Medical Treatment (LIC627); Identification and Emergency Information (LIC700); Affidavit Regarding Liability Insurance (LIC282); and Immunization Record.

Assistant’s Cardiopulmonary Resuscitation/ First Aid Certification (CPR) was current, expiring: 3/2026.

LPA reminded facility to ensure disaster drill are conducted every six months. Advisory Note: Technical Violation (LIC9102TV) was issued.

The required forms are posted in facility and include the: Child Care License; Notification of Parent’s Rights (PUB379); and Disaster Plan (LIC610A).

Per licensee, isolation of an ill child is in the kitchen. Per licensee, the program provides daily snacks and lunches for children in care.

Facility 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: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: AMADOR,YOLANDA I.
FACILITY NUMBER: 384004553
VISIT DATE: 06/20/2024
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LPA discussed the safe sleep regulations with licensee and the 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.

Facility 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, no deficiencies were cited in areas evaluated according to California Title 22, Div. 12 Chap. 3, Health and Safety, Code of Regulations. Exit interview and report was reviewed with Juan Valderramos. Licensee’s signature of this form acknowledges the receipt of these documents.

During exit interview, Licensee’s son confirmed no registered sex offenders are living in the facility and LPA completed 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: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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