384004701-1-7-2025-05-CC-JGIL-DCPQVA-20250107113002

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 384004701
Report Date: 01/07/2025
Date Signed: 01/07/2025 11:30:13 AM

Document Has Been Signed on 01/07/2025 11:30 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:	DOMINGUEZ, MATILDE		FACILITY NUMBER:	384004701
ADMINISTRATOR/ DIRECTOR:	DOMINGUEZ, MATILDE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(209) 777-4584
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94114
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 11	DATE:	01/07/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:20 AM
MET WITH:	Matilde Dominguez(Tilly)		TIME VISIT/ INSPECTION COMPLETED:	12:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On January 7th, 2025, at approximately 9:20 AM, Licensing Program Analyst (LPA) Janet Gil conducted an unannounced, annual inspection. LPA met with licensee, Matilde Dominguez(Tilly), and explained the purpose of the inspection. Present during LPA’s visit included licensee, 2 assistants and 11 enrolled children (2 infants and 9 preschoolers). The licensee is a large license and is operating within capacity limits and ratio. Licensee rents home, which is a 4 bedrooms, 3 bathrooms, multi level home. Licensee lives in home. All adults living and working in the home have fingerprint clearance. Facility operates Monday Through Friday 8:00 AM to 5:00 PM. Day Care Areas: Playroom, Upstairs Loft Area, Dining Room next to Kitchen, Bathroom next to Kitchen area, Outdoor Yard, Playhouse, Outdoor Nap Room Off Limit Areas: Master Bedroom (and bathroom located in room), Office, Kitchen, Garage, Outdoor Deck and Hall At approximately 9:45 AM, LPA toured day care areas of home with licensee. LPA observed the home to be in repair with proper temperature and ventilation. Home is equipped with a variety of toys and materials that were observed to be in working condition. LPA observed a fully stocked accessible first aid kit located in the playroom. LPA did not observe any accessible cleaning supplies, poisons, and solutions in day care areas. LPA observed electrical outlets to be made inaccessible with outlet covers. Home is equipped with multiple fully charged fire extinguishers and multiple smoke and carbon monoxide detectors. LPA tested carbon monoxide detector in Dining Room Area and back yard Nap Room. All alarms were observed to be working. Licensee does not have any children in care with allergies or IMS plans. Per licensee, she provides all foods for the children in care. At approximately 10:20 AM, LPA observed bathroom for children's use was in proper working condition. LPA observed bathroom to include appropriate toileting equipment and sanitation products. LPA did not observe any hazardous materials to be accessible to children in the bathroom. Continue on Page 2...

SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Janet Gil
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025

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: 01/07/2025

NARRATIVE

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The entire backyard is fully enclosed. LPA observed all stair ways outdoors to be properly barricaded with gates. The outdoor area is equipped with a variety of toys and materials. LPA did not observe any pools, spas, or bodies of water in day care areas.

LPA reviewed six children records which were complete. The children’s files have a record of emergency identification information and required immunization. LPA reviewed staff records for licensee and two assistant staff. At least one staff has a valid CPR/FIrst Aid certificate is current and will expire 4/2025. The licensee also has required immunization available for review. LPA reminded licensee to keep all printed certificates printed in each staff file 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 on December 20th, 2024. 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: 01/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: 01/07/2025

NARRATIVE

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LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage athttps://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.

On this date, 1/3/2025, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

During the exit interview, the licensee, Matilde Dominguez(Tilly), 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(Tilly).

SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Janet Gil
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025

LIC809 (FAS) - (06/04)

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