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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414002998
Report Date: 03/06/2025
Date Signed: 03/06/2025 05:15:05 PM

Document Has Been Signed on 03/06/2025 05:15 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:JIMENEZ, EVELYN P.FACILITY NUMBER:
414002998
ADMINISTRATOR/
DIRECTOR:		JIMENEZ, EVELYN P.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 804-5474
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 5DATE:
03/06/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:13 PM
MET WITH:Evelyn JimenezTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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On March 6, 2025, @ approx. 2:15 pm, Licensing Program Analysts (LPAs) Maria Olguin-Leon and Ruhi Wadhwa met with Licensee Evelyn Jimenez to conduct an unannounced annual inspection. The purpose of the inspection was explained to licensee. Present during today’s visit was licensee, spouse, helper and 5 children (4 infants (one infant was licensee child) & 1 preschoolers). All adults present have criminal background clearances. Facility is operating within capacity and ratio requirements on this day. Hours of operation are Monday– Friday, 8:00 am – 5:00pm.

LPAs and licensee toured the home for health and safety hazards. The DAY CARE AREAS: are living room, dining room, hallway, kitchen, bedrooms #1 & #2 are used for napping only, bedroom #3 (playroom), office, two bathroom and backyard. A changing table is located in Office. OFF-LIMIT AREAS: Detached garage. Home has proper ventilation and lighting throughout home. LPA observed electrical outlets covered with childproof covers or located behind furniture. There is a childproof gate between kitchen and hallway. Cleaning supplies and other potentially harmful items are stored inaccessible to children in care. There are plenty of age-appropriate toys, child size furnishings, learning material, and cribs/playpens, all in good condition. Bathrooms were clean and equipped with children's toiletries and cabinet was equipped with a child proof lock. At approx. 2:30 pm LPAs observed children sleeping in bedrooms with door closed, type B deficiency issued. LPAs observed three children in sleep sacks and blankets in cribs/playpens, type B deficiency issued. Backyards is equipped with a small play slide structure, a playhouse, and ride on toys, all in good condition. LPAs observed canopies in backyard to provide shade to children in care. Backyard is equipped with artificial grass to cushion falls. The entire backyard is equipped with a 5 ft. wood fence. LPAs did not observe any spas, pools, or other bodies of water.

Home is equipped with working dual carbon monoxide/smoke detector and a fully charged fire extinguisher located in office. Isolation area for ill children will be in living room and away from other children. First aid kit is fully stocked with supplies. Licensee uses a cell phone on the premises. Per licensee, there are no weapons or firearms in the home. Parents provide sheets for playpens and are sent home weekly for laundering.

Cont. Page 2...
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Maria Olguin-Leon
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2025
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: JIMENEZ, EVELYN P.
FACILITY NUMBER: 414002998
VISIT DATE: 03/06/2025
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LPAs reviewed 4 children’s files and 1 staff file. LPAs reminded licensee to keep a file for all children, including siblings and relatives. LPAs discussed 15-minute sleep logs with licensee, type B deficiency issued. Licensee CPR/FA BLS expires 10/2025, LPAs reminded Licensee to complete CPR/FA via authorized provider. Technical violation was issued for Mandated Reporter training certificate was unavailable. Licensee provides meals to children in care, which includes breakfast, lunch and two snacks. LPAs reminded licensee to label children's food/bottles brought from home. Licensee keeps an updated children’s roster. LPAs observed Childcare License, Emergency Disaster Plan (LIC610A) and Parent's rights posted. Last emergency drill was conducted on January 27, 2025 and properly documented. Licensee carries liability insurance via Farmer's Insurance which expires 12/2025.

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.

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 reminded about the Provider Information Notices (PINs) on the CCLD website. 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 against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662. LPAs reviewed AB 1207 with the Licensee.

As of January 1, 2018, all staff must complete Mandated Reporter Training every two years. LPA reminded licensee about Mandated Reporter training available www.mandatedreporterca.com

Cont. page 3...
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Maria Olguin-Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
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: JIMENEZ, EVELYN P.
FACILITY NUMBER: 414002998
VISIT DATE: 03/06/2025
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LPAs 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-and-resources/safe-sleep as an additional resource. LPAs 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 LPAs discussed ban of sleep sack with licensee.

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

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

See page LIC809D for type B deficiencies issued today, under CCR, Title 22, Division 12.

A notice of site visit was given and must remain posted for 30 days. Appeal Rights were provided.

Exit interview conducted and report was reviewed with licensee, Evelyn Jimenez.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Maria Olguin-Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/06/2025 05:15 PM - It Cannot Be Edited


Created By: Maria Olguin-Leon On 03/06/2025 at 04:26 PM
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: JIMENEZ, EVELYN P.
FACILITY NUMBER: 414002998

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(b)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in three children were observed wearing sleep sack and there were blankets and pacifiers in the playpen/cribs, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/07/2025
Plan of Correction
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Licensee will not use sleep sacks and will be sending sleep sacks home to parents. Licensee will not allow any objects in the playpen/crib while children are sleeping.
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in 4 out of 4 infants were missing 15 minute sleep logs, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/21/2025
Plan of Correction
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Licensee will maintain 15 minute sleep logs for all infants under 24 months old. Licensee will email LPA two week worth of sleep log for all infants by POC date.
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:Marie Rodriguez
LICENSING EVALUATOR NAME:Maria Olguin-Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/06/2025 05:15 PM - It Cannot Be Edited


Created By: Maria Olguin-Leon On 03/06/2025 at 04:26 PM
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: JIMENEZ, EVELYN P.
FACILITY NUMBER: 414002998

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(5)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: If the infant is sleeping in a separate room from where the provider is stationed, the door to the room the infant is sleeping in shall remain open at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations the licensee did not comply with the section cited above in two bedrooms doors were closed while children were sleeping, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/07/2025
Plan of Correction
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Licensee understands door to bedrooms must remain slightly opened while children are napping. Licensee need to be able to observe napping children without moving door. Licensee will be leaving the door open.
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:Marie Rodriguez
LICENSING EVALUATOR NAME:Maria Olguin-Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2025


LIC809 (FAS) - (06/04)
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