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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004701
Report Date: 03/15/2023
Date Signed: 03/15/2023 04:56:07 PM

Document Has Been Signed on 03/15/2023 04:56 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 CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:DOMINGUEZ, MATILDEFACILITY NUMBER:
384004701
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
03/15/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Dominguez, MatildeTIME COMPLETED:
04:45 PM
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 On March 15, 2023., Licensing Program Analyst (LPA) Van met with applicant Matilde Dominguez for an announced pre-licensing inspection. The Applicant rents this single-family home consisting of two bedrooms and two bathrooms. The home resident is the only Applicant. The Applicant plans to operate from 8:00 am – 5:00 pm Monday- Friday.
LPA and the Applicant inspected the entire home for Health and Safety Hazards. Daycare areas are the Living Room, Half side of the Kitchen, Bathroom #2, bedroom #2/nursery, and 1/2 Backyard. OFF-limit areas are the Applicant's bedroom #1, bathroom#1 inside bedroom #1, Loft, furnace room, the other half of the Kitchen, and the storage room next to the backyard. All off-limit areas, including closets, are adequately barricaded. Per Applicants, all toxic or dangerous chemicals are stored in an off-limit area, making them inaccessible to children. The use of baby-gate barricades in all off-limit areas.
LPA observed three baby cribs inside the nursery room. LPA advised the Applicant that cribs should have no toys or pillows inside and no objects hanging above the cribs. All mattresses shall be designed for that cribs, and bedsheets should be tight-fitted. Booster chairs are used only when children are eating/feeding. In addition, the Applicant was advised to check on the infant every 15 minutes during naptime physically, and documentation shall be maintained in the infant's file and be available to the Department for review.
Per Applicant, there are no firearms, weapons, or pets in the home. The isolation area for sick/ill children will be under the loft area. The house has multiple smoke alarms & carbon monoxide combination detectors. During the inspection, all detectors were tested and worked.
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SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE: DATE: 03/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/15/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: DOMINGUEZ, MATILDE
FACILITY NUMBER: 384004701
VISIT DATE: 03/15/2023
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 The daycare has sufficient age-appropriate toys, furniture, and napping equipment. The children's bathroom is clean and sanitation. The Applicant plans to provide morning and afternoon snacks to children. The Applicant was informed that NO baby walkers, exer-saucers, jumpers, bouncers, and similar items for children in care should be made inaccessible. LPA also reminded the Applicant that smoking is prohibited at the daycare.
Posting Parent's Rights and the Emergency Disaster Plan was reviewed with the Applicant during the inspection. Records to be maintained were consulted and reviewed with the Applicant. LPA advised the Applicant to conduct an emergency drill once every six months and document the exercises. The Applicant was informed to obtain a copy of regulations and current licensing forms through the Department's website at www.ccld.ca.gov. LPA also reminded the Applicant of the Family Child Care Home License's responsibilities and Reporting requirements. The Applicant was advised to post the License when she received it.
The Applicant was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record 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 the Applicant and discussed the Child Care Licensing Safe Sleep webpage https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed the Applicant of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.
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SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023
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 CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: DOMINGUEZ, MATILDE
FACILITY NUMBER: 384004701
VISIT DATE: 03/15/2023
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 This facility plans to provide Incidental Medical Services – IMS. For IMS information, see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. A Plan for Providing 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
The Applicant was informed about the Provider Information Notices (PINs) on the CCLD website and the sign-up process. The Applicant was also reminded of Mandated Reporter Online Training for Child Care Providers (AB 1207) and the additional General Training, and both are available on www.mandatedreporteca.com. The Applicant was informed that as of September 1, 2016, a person may not be employed or volunteer at a childcare facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662.

The Applicant's home meets the licensing requirements of a Small Family Child Care Home (FCCH) today, and licensure is recommended and approved today, 3/15/2023.

The report was reviewed and signed by the Applicant, Matilde Dominguez. This report will be kept in the facility file and available for public review upon request. Desk duty is available Monday - Friday, 8:00 am - 5:00 pm. (650) 266-8800. Website for Forms and Regulations: www.cdss.ca.gov.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023
LIC809 (FAS) - (06/04)
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