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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414000100
Report Date: 03/13/2024
Date Signed: 03/13/2024 12:15:59 PM

Document Has Been Signed on 03/13/2024 12:15 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:NAVA, PAULETTE & RICHARDFACILITY NUMBER:
414000100
ADMINISTRATOR:NAVA, PAULETTE & RICHARDFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 346-2393
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 12TOTAL ENROLLED CHILDREN: 18CENSUS: 0DATE:
03/13/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Paulette NavaTIME COMPLETED:
12:35 PM
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On March 13th, 2024, at approximately 9:00 AM, Licensing Program Analyst (LPA) Janet Gil conducted an unannounced, annual inspection. LPA met with licensee, Paulette Nava, and explained the purpose of the inspection. Present during LPA’s visit were licensee and licensees’ husband. At time of LPA's visit there were no enrolled children or other staff were present. Licensee operates an after school program for children over the age of five. Per licensee, she operates a Montessori program in two separate groups. The first group is with Kindergarteners from approximately 12:30pm to 3:00pm. The second group occurs with older school age children from approximately 3:00pm to 6:00pm. All individuals living and/or working in the home have fingerprint clearance on file. Licensee owns a multi-level home and has current Markel Day Care insurance.

Day Care Areas: living room, dining room, garage (playroom), bathroom #1 (at the end of the hallway), bathroom #2 (located in dining room), front yard, side yard and backyard.
Off-Limit Areas: the entire second level of the home, bedrooms located on first level of the home, and kitchen. All off limit areas are properly barricaded with child safety gates and/or locked doors.

LPA toured day care areas of home with licensee. LPA observed a properly barricaded fireplace in the living room area. 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 two fully stocked accessible first aid kits. LPA did not observe any accessible cleaning supplies, poisons, and solutions in day care areas. Home is equipped with a fully charged fire extinguisher and a smoke/carbon monoxide detector. LPA tested detector in garage area, which was observed to be working. LPA did not observe any hazardous materials accessible. Safety locks are installed in all cabinets of the garage. Licensee does not have any children in her after school program that have any allergies or medications. Per licensee, she only provides snack for the children in her care. Parents of children provide lunches for their children.

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SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Janet Gil
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2024
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: NAVA, PAULETTE & RICHARD
FACILITY NUMBER: 414000100
VISIT DATE: 03/13/2024
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Bathroom for children's use was observed to be 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. There is a working telephone on site. Per licensee, there are no weapons or firearms in the home.

The entire backyard is enclosed with an at least 5ft high fence. The yard includes an above ground fishpond that is properly barricaded and covered. The backyard is equipped with appropriate outdoor toys and materials that were in good working condition. The backyard also contains a climbing structure that has padding underneath. Outdoor area also includes a chicken coop that was properly barricaded and locked.

LPA reviewed five random children's records which were not complete. Children's records have a record of emergency identification information on file, however are missing parents rights forms and consent form for emergency medical treatment. LPA reminded licensee to have these two additional forms added to her children’s files once filled out by the parents. LPA reviewed licensee's file and three other staff files. Staff were not present during inspection. Licensee’s files were complete. Staff files were incomplete. LPA reminded licensee that she must have all immunization records for her assistants. Licensee has a current and valid CPR certificate that will expire 05/2024. All staff have mandated reporter certificates on file. Licensee’s Mandated reporter certificate will expire on 2/07/2026.

Emergency drills are conducted at least once every six months and are properly logged and documented. Last emergency disaster drill was conducted 03/2/2024.

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.


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SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Janet Gil
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024
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: NAVA, PAULETTE & RICHARD
FACILITY NUMBER: 414000100
VISIT DATE: 03/13/2024
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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

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.

During the exit interview, the licensee, Paulette Nava, 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, Paulette Nave.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Janet Gil
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024
LIC809 (FAS) - (06/04)
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