384004701-3-26-2024-05-CC-JGIL-D3QQG5-20240326120900

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 384004701
Report Date: 03/26/2024
Date Signed: 03/26/2024 12:09:06 PM

Document Has Been Signed on 03/26/2024 12:09 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:	DOMINGUEZ, MATILDE		FACILITY NUMBER:	384004701
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS:	DATE:	03/26/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Matilde Dominguez		TIME COMPLETED:	12:35 PM

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On 3/26/2024, at approximately 9:30 AM, Licensing Program Analyst (LPA) Janet Gil conducted an unannounced Case Management/Annual- Licensee Initiated inspection. LPA met with Licensee, Matilde Dominguz and explained the purpose for the inspection. On 03/11/2024 the licensee applied for a Large Family Child Care Home (FCCH). The licensee has been licensed since 03/15/2023 and therefore has at least one year of experience to apply for a large Family Child Care Home. A fire clearance was granted on 03/05/2024 by the San Francisco Fire Department. Present during today's inspection were Licensee, one assistant and seven children in care 4 infants and 3 preschoolers.

Licensee lives in a multi-level home. All adults living in the home have fingerprint clearance on file. The hours of operation are Monday through Friday 8:00 AM to 5:00 PM/ The home includes 1 loft area, 3 bedrooms, 2 bathrooms, living/playroom, kitchen/dining area, backyard, backyard play house and garage.

Day Care Areas: Playroom, Upstairs loft area, Dining room next to kitchen, Bathroom next to Kitchen area, Outdoor Yard, Playhouse

Off-limit areas: Master Bedroom (and bathroom located in room), Office,Kitchen, Garage, Outdoor Deck and Hall

LPA toured day care areas of home with licensee. LPA observed the home to be in good repair with proper temperature and ventilation. Home is equipped with a variety of toys and materials that were observed to be in good working condition. LPA observed a fully stocked accessible first aid kit. LPA did not observe any accessible cleaning supplies, poisons, and solutions in day care areas. Home is equipped with two fully charged fire extinguishers and multiple carbon monoxide detectors. The licensee also has a fire alarm by the front entrance. LPA tested carbon monoxide detector in Kitchen area, which was observed to be working. LPA did not observe any hazardous materials accessible in kitchen area. Licensee does not have any children enrolled with allergies and medications. Per licensee, she provides all food for the children in her care.

Bathroom for children's use was observed to be in proper working condition. LPA observed bathroom to include appropriate toileting equipment and sanitation products. Safety locks are installed in all cabinets of the bathroom. LPA did not observe any hazardous materials to be accessible to children in the bathroom.

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SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Janet Gil
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024

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 CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: DOMINGUEZ, MATILDE	FACILITY NUMBER: 384004701
	VISIT DATE: 03/26/2024

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There is a working phone in the home. The licensee rents the home; and has Markel insurance for her Day Care. LPA observed licensee to utilize a playpens for her infants and sleeping cots for her preschool children in care. The entire backyard is fully enclosed. The outdoor area is equipped with a variety of toys and materials. LPA did not observe pools, spas or bodies of water.

LPA reviewed five children’s records which were incomplete. All children’s file had record of emergency identification information and consent forms for emergency medical treatment. Two infants were missing LIC 9227 and one preschooler was missing their immunization record(C5). LPA advised Licensee to have all proper documentation for the children in care in their files and available for review by the department. LPA reviewed staff records for licensee which were complete. Licensee's CPR/First Aid is current and will expire 06/2024. The licensee’s Mandated Reporter training certification is also current and will expire 08/2024. The licensee and assistant also have required immunization available for review.

Licensee has licensing documentation properly posted and available for review. The licensee also maintains a childcare roster that was made available for review. Emergency disaster drills are conducted at least once every six months. The last disaster drill was conducted in December 8^th, 2023. Per licensee, there are no weapons or firearms in the home.

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 CARE tools, please send email inquiries 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/inforesources/community-care-licensing/inspection-process.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 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.

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SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Janet Gil
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024

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: DOMINGUEZ, MATILDE	FACILITY NUMBER: 384004701
	VISIT DATE: 03/26/2024

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LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at
https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed licensee 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, 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: https://www.ada.gov/resources/child-care-centers/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Licensee was informed that upon receipt of Licensing Management's approval, a license for a Large Family Child Care Home will not be granted and issued to Licensee, Matilde Dominguez until LIC 9227 forms needed from 3/26 visit are made and sent to department for review.

During the exit interview, the licensee, Matilde Dominguez, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

No deficiencies were cited today under CCR, Title 22, Div. 12, Chapt. 1.
A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee, Matilde Dominguez.

SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Janet Gil
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024

LIC809 (FAS) - (06/04)

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