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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414001369
Report Date: 06/28/2022
Date Signed: 06/28/2022 05:19:22 PM

Document Has Been Signed on 06/28/2022 05:19 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:HERNANDEZ, ROSARIO INGRIDFACILITY NUMBER:
414001369
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 9DATE:
06/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:28 AM
MET WITH:Rosario HernandezTIME COMPLETED:
01:05 PM
NARRATIVE
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On 6/28/2022 at 9:28AM., Licensing Program Analysts (LPA's), Luis J. Gomez and April Cowan met with Licensee, Rosario Hernandez. Purpose of the inspection was explained and was for an unannounced; annual random inspection. Present in facility was the licensee and helper caring for nine children (five infant and four preschool age). Adults have their criminal record clearances on file. Licensee’s home is a three bedroom, one bathroom, one level house. Days and hours of operation are: Monday- Friday; 8:00am- 5:00pm. Daycare areas are: Living Room (Playroom #1), Bedroom #1, Bathroom #1 and Outdoor Play Area #1 and #2. Off Limit areas are: Bedroom #2, Bedroom #3, Family Room, and Kitchen (Pass through only). LPA inspected home, inside and outside, with the licensee for health and safety hazards.

At 9:45AM., the following was observed: home was clean, orderly, and with age-appropriate toys available for the children. Playthings inspected were in good repair Furniture inspected was free of any sharp edges. Playroom was equipped with soft padding for added fall safety. For napping services, play pens are stored in bedroom#1. Mattresses inspected were the proper size with tight-fitting sheets. Facility had at least one crib available for each infant age child in care. Bathroom #1 was observed clean and with supplies. Bathroom fixtures tested were in proper order. The off-limit areas been made inaccessible with child safety gate. Accessible outlets and trash bins had been covered. Cleaning detergents, compounds, wipes, spray bottles and items which could pose a danger, were stored inaccessible to day-care children. Facility was the proper temperature, with ventilation and lighting. Home had functioning telephone; smoke/ carbon monoxide detector; and one fully charged fire extinguishers (2A:10BC). (REFER TO 809C FOR CONT.)
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2022
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 7
Document Has Been Signed on 06/28/2022 05:19 PM - It Cannot Be Edited


Created By: Luis Gomez On 06/28/2022 at 11:03 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: HERNANDEZ, ROSARIO INGRID
FACILITY NUMBER: 414001369

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(b)(2)
Staffing Ratio and Capacity
(b) For a Small Family Child Care Home, the maximum number of children for whom care may be provided at any one time, including children under age 10 who reside at the licensee's home, shall be one of the following: (2) Six children, no more than three of whom may be infants; or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, interview and observations conducted; LPA's confirmed licensee is over capacity with nine children (five infants) in care. This poses an immediate health and safety risk to children in care.
POC Due Date: 07/04/2022
Plan of Correction
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Licensee will reduce total child enrollment to required capacity stated on license by the due date: 7/4/2022.

Proof of correction and updated schedule will be submitted to the Department via email.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Cindy Interiano
LICENSING EVALUATOR NAME:Luis Gomez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/28/2022 05:19 PM - It Cannot Be Edited


Created By: Luis Gomez On 06/28/2022 at 11:03 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: HERNANDEZ, ROSARIO INGRID
FACILITY NUMBER: 414001369

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on At 10:25AM., Based on record review and interview, LPA confirmed day-care child's (C9) Immunization records missing from children's files. This poses a potential health and safety risk for children in care.
POC Due Date: 07/08/2022
Plan of Correction
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Licensee will submit proof of correction to the Department by the due date: 7/8/2022. Proof of correction will be submitted via email.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Cindy Interiano
LICENSING EVALUATOR NAME:Luis Gomez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2022


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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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: HERNANDEZ, ROSARIO INGRID
FACILITY NUMBER: 414001369
VISIT DATE: 06/28/2022
NARRATIVE
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At 9:55AM, LPA's inspected Outdoor Play Area. Outdoor area was completely enclosed and free of debris. Play items inspected where in good repair. Outdoor area had sufficient shading available for the children. Home did not have any swimming pools, spas, hot tubs, fishponds or other bodies of water.

At 10:10AM., LPA's reviewed the facility and children’s records. Children's records were reviewed and included, (LIC700) Identification of Emergency Information; and (LIC995A) Notification of Parent’s Rights.

At 10:25AM., Based on record review and interview, LPA's confirmed day-care child's (C9) Immunization records missing from children's files.

Facility Records were reviewed and included: Criminal Record Statement; Declaration to Report Suspected Child Abuse; and Employee Rights. LPA's reminded licensee to have staff's proof of required immunization in the staff records.

At 10:30AM., Based on record review, LPA's confirmed staff's mandated reporter training has expired. During inspection Advisory Note: Technical Assistance (LIC9102TA) was issued.

LPA reminded licensee to maintaining infant napping logs, with documentation for each 15 minute check.

At 11:00AM., Based on record review, interview and observations conducted; LPA's confirmed licensee is over capacity with nine children (five infants) in care. Per licensee, she has a applied for large capacity licensure.

Provider's Cardiopulmonary Resuscitation (CPR)/ First Aid Certification was current, expiring 6/4/2024.

Facility is conducting emergency disaster drill, with last drill completed on 6/23/2022. LPA reminded licensee to log all disaster drills conducted.

LPA's observed postings including: Facility Childcare License, Notification of Parent’s Rights, and Emergency Disaster Plan. Children's Roster (LIC500) was reviewed during inspection. Per licensee, isolation of an ill child is in the playroom.

Per licensee, facility provides all lunch and snack for children in care. LPA's asked staff to ensure all children’s food containers brought to facility by families are properly labelled. Per licensee, home does not have any no guns or weapons. (REFER TO 809C, FOR CONT.)

SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022
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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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: HERNANDEZ, ROSARIO INGRID
FACILITY NUMBER: 414001369
VISIT DATE: 06/28/2022
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(Page 3)
Licensee was reminded that all adults 18 years and over living or working in the home, including employee and volunteers, 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 up to $500.00 maximum per day/ per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with licensee and discussed 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.

To improve the quality and value of the new inspection process, a survey will 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, deficiencies were observed in areas evaluated, according to California Title 22, Health and Safety Code of Regulations. Exit interview, report and plan of correction was reviewed with Licensee, Rosario Hernandez and signature of this form acknowledges receipt of these documents.



Type “A” violations were issued today. Facility is advised to provide a copy of the Evaluation Report and the Type “A” Deficiencies cited, to the parents and guardians of children currently enrolled in care and to parents of newly enrolled children during the next 12 months. A signed and dated LIC 9224 (Deficiency and Acknowledgment of Receipt of Licensing Reports) shall be maintained in all Children's files.

Notice of Site Visit was provided and must remain posted for 30 days.

This report must be available in the facility for public review. Licensee was advised any additional questions to call Office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022
LIC809 (FAS) - (06/04)
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