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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414001369
Report Date: 07/22/2022
Date Signed: 07/22/2022 11:20:11 AM

Document Has Been Signed on 07/22/2022 11:20 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
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: 5DATE:
07/22/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Rosario Ingrid HernandezTIME COMPLETED:
11:45 AM
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On 7/22/2022 at 9:00AM., Licensing Program Analyst (LPA), Luis J. Gomez met with Licensee, Rosario Ingrid Hernandez. Purpose of inspection was explained and was for an unannounced; Case Management inspection for increase in capacity. Present during inspection was licensee and helper/occupant caring for five children (3 Infant Age, 2 Preschool Age). All adults have their criminal record clearances on file. Licensee’s home is a three bedroom, one bathroom, one level house. Days and Hours of operations are: Monday – Friday, 8:00 A.M., to 5:00 P.M. Daycare areas are: Living Room (Playroom); Bedroom #1 (Napping only); Bathroom; 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 9:05AM., LPA observed the following: Day-care was clean and orderly. Playroom was equipped with age-appropriate toys, blocks and games for the children. Playthings and furniture inspected were in good repair. Licensee has child size table and chairs for snack and activities. Playroom floor had soft padding installed for added safety. Off-limit area have been properly barricaded with child safety gate. For napping services, LPA observed several infant playpens and cots located in bedroom #1. Bathroom was reviewed during inspection. Bathroom #1 was clean and had adequate supplies for handwashing. Facility has a functioning cell phone, smoke /carbon monoxide detector combo, and fire extinguisher (3A:40BC), located next to playroom. LPA observed pull alarm installed on kitchen wall.

At 9:25AM., LPA inspected outdoor play yard. Play yard was completely enclosed with tall fencing. Items inspected were in good repair. Outdoor area had accessible shading for children in care. Home does not have a swimming pool, spa, hot tub, fish pond or any other bodies of water.

At 9:35AM., LPA and applicant reviewed the Records to Keep in Your Family Child Care Home (LIC311D); Children's Forms/ Records, Facility Forms; and Information to be Posted. (REFER TO 809-C FOR CONT.)

SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2022
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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: HERNANDEZ, ROSARIO INGRID
FACILITY NUMBER: 414001369
VISIT DATE: 07/22/2022
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Applicant's Cardiopulmonary Resuscitation / First Aid certification was current, expiring 6/4/2024. Applicant’s Mandated Reporter Certification (AB1207) was current, expiring 7/19/2022. Updated Preventive Health and Safety Practices was completed by licensee.

Required forms are posted in facility and include the Childcare License, Notification of Parent's Rights (LIC995A) and Emergency Disaster Plan (LIC610A).

During inspection, LPA reviewed COVID-19 Self- Assessment with migration methods were reviewed with licensee. Licensee was informed that the Department must be notified prior to the use of designated off-limits areas.

Licensee 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 for influenza, pertussis and measles or qualifies for an exemption pursuant to Health and Safety Code 1596.7995 and 1597.662.

Licensee was informed 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 Webpage 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

Large license capacity limits were reviewed with licensee. Licensee was reminded that when operating at a large capacity, there must be at least one helper present.

Fire Clearance Approval was received by the Department on 7/19/2022.


During inspection licensee submitted the following: LIC508, LIC9217, and Proof of Immunization.

Prior to recommendation for Increase in Capacity, licensee must submit the following documents:
-Submit proof of licensee’s proof of required immunization
-Submit updated Control of Property

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

DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022
LIC809 (FAS) - (06/04)
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