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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004153
Report Date: 10/10/2024
Date Signed: 10/10/2024 08:00:44 PM

Document Has Been Signed on 10/10/2024 08:00 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:ROSALES, ROSALVAFACILITY NUMBER:
414004153
ADMINISTRATOR/
DIRECTOR:		ROSALES, ROSALVAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 787-5736
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY: 14TOTAL ENROLLED CHILDREN: 5CENSUS: 5DATE:
10/10/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:32 PM
MET WITH:Esmeralda ManzoTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
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On October 10, 2024, at approximately 1:35pm, Licensing Program Analyst (LPA) Maria Olguin-Leon conducted an unannounced annual inspection and met with helper Esmeralda Manzo, and purpose of inspection was explained. Helper granted LPA entry into home. Present during today’s visit was Helper and 5 children (4 infants and 1 preschoolers). At approx. 2:08, licensee arrived home. During the time licensee was not present, facility was operating out of capacity and ratio requirements, type A deficiency cited. Facility hours of operation are Monday - Friday from 8:00am to 5:30pm.

LPA toured and inspected the indoors and outdoors of home for health and safety hazards. Home is a single level home. Day Care Areas: Living room, dining room, bedroom #4, enclosed deck and bathroom #1, and backyard. Off Limits Areas: Bedrooms #1, #2, and #3, kitchen,and garage. Isolation area for ill children will be in the living room and away from other children. LPA observed home to be clean with proper lighting and ventilation. Per licensee, current children in care are not using the bathroom. LPA reminded licensee to always keep personal toiletries stored in locked cabinets. LPA observed electrical outlets are secured with furniture and outlet covers. LPA observed kitchen is equipped with child proof gates for inaccessibility to children in care. Fireplace located in living room is barricaded with a screen and a playpen. There are plenty of age-appropriate toys, books, child size furnishings, storage hooks, storage cubbies, cribs, and playpens. Type B deficiency was issued for usage of banned baby equipment; exersaucers and inclined sleeper. Type B deficiencies issued for safe sleep regulations. Outdoors play area is equipped with a swing/slide play structure, which is properly anchored. Outdoor play toys also include a playhouse, climbing dome, sand box, playhouses, and ride on toys, all in good condition. Outdoor flooring is artificial grass to cushion falls, LPA reminded licensee to maintain artificial grass for tripping hazards. The remainder of outdoor flooring is tile bricks. LPA observed canopies in backyard for providing shade to children in care. The entire backyard is surrounded with a 5 ft. fence. LPA did not observe any spas, pools, or other bodies of water.

Cont. page 2…
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Maria Olguin-Leon
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: ROSALES, ROSALVA
FACILITY NUMBER: 414004153
VISIT DATE: 10/10/2024
NARRATIVE
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LPA observed a working carbon monoxide and working smoke detector. A fully charged fire extinguisher is located on a wall between dining room and kitchen. LPA reviewed first aid box located in kitchen/dining room wall. Licensee uses a landline and a cell on the premises. Per licensee, there are no weapons or firearms in the home. Parents provide sheets for cribs and playpens and are sent home for washing on a weekly basis.
LPA reviewed 5 children’s files, which included LIC282 and LIC9150. LPA reminded licensee to keep updated and daily sleeping logs for all children under the age of 24 months. LPA reviewed 2 staff files, 1 staff was missing file, type B deficiency cited. Licensee maintains an updated Children’s roster. Licensee CPR/First Aid is current and expires 07/2025. Licensee Mandated Reporter training expires 06/2026. Licensee provides meal to children in care, which includes breakfast, lunch and two snack. LPA reminded Licensee to label children's food/bottles brought from home, technical violation issued. LPA observed Childcare License, Emergency Disaster Plan (LIC610A) and Parent's rights posted. Last emergency drill was conducted on 08/02/2024 and is properly documented on a dry erase board.

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/.

The 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. LPA's reviewed AB 1207 with the Licensee.

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

DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024
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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: ROSALES, ROSALVA
FACILITY NUMBER: 414004153
VISIT DATE: 10/10/2024
NARRATIVE
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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, Type B issued for staff missing mandated reporter training certificate.

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-and-resources/safe-sleep as an additional resource. LPAs also informed licensees 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. LPA reminded licensee of banned equipment; Type B deficiencies were cited.

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 childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the LICENSEE, Rosalva Rosales confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.



**See following page for deficiencies cited against the facility today under CCR, Title 22, Div. 12, Chapt. 1**

Cont. page 4...
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Maria Olguin-Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024
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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: ROSALES, ROSALVA
FACILITY NUMBER: 414004153
VISIT DATE: 10/10/2024
NARRATIVE
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Type “A” deficiency was issued today. Licensee is advised to provide a copy of the Evaluation Report and all 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 shall be maintained in all Children's files.

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

Exit interview conducted and report was reviewed with the licensee, Rosalva Rosales, LPA translated report in Spanish.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Maria Olguin-Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024
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Document Has Been Signed on 10/10/2024 08:00 PM - It Cannot Be Edited


Created By: Maria Olguin-Leon On 10/10/2024 at 04:32 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: ROSALES, ROSALVA
FACILITY NUMBER: 414004153

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(e)
Staffing Ratio and Capacity
(e) If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home as specified in subsections (b) and (c).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above in S3 was left alone with 4 infants and 1 preschool child, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/11/2024
Plan of Correction
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2
3
4
Licensee will ensure there are two helper with children at all times, while licensee is unavailable,
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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: 10/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2024


LIC809 (FAS) - (06/04)
Page: 5 of 11
Document Has Been Signed on 10/10/2024 08:00 PM - It Cannot Be Edited


Created By: Maria Olguin-Leon On 10/10/2024 at 04:32 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: ROSALES, ROSALVA
FACILITY NUMBER: 414004153

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(d)(1)
Operation of A Family Child Care Home
(d) The home shall provide safe toys, play equipment and materials. (1) Fixtures, furniture, and equipment that have been banned or recalled by the United States Consumer Product Safety Commission shall not be used for children in care or accessible to children in care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation and interview the licensee did not comply with the section cited above in LPA observed three banned exesaucers in home and observed an infant in one of the exersaucer, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/11/2024
Plan of Correction
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Licensee will remove exersaucers from home.
Type B
Section Cited
CCR
102425(a)(1)
Infant Safe Sleep
(a) There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard. (1) All cribs or play yards shall meet the United States Consumer Product Safety Commission safety standards.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in one child was sleeping in a banned fisher price inclined sleeper, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/11/2024
Plan of Correction
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3
4
Licensee will remove inclined sleeper from home.
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: 10/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2024


LIC809 (FAS) - (06/04)
Page: 6 of 11
Document Has Been Signed on 10/10/2024 08:00 PM - It Cannot Be Edited


Created By: Maria Olguin-Leon On 10/10/2024 at 04:32 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: ROSALES, ROSALVA
FACILITY NUMBER: 414004153

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2024

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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in LPA observed blankets and stuffed animals in cribs, playpen and inclined sleeper, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/11/2024
Plan of Correction
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Licensee will inform parents of safe sleep regulations and reminded parents that infants can not sleep in crib/playpens with blankets or stuffed animals. Licensee will put infants to sleep with no blankets or stuffed animals.
Type B
Section Cited
CCR
102425(b)(3)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects. (3) There shall be no objects hanging above or attached to the side of the crib.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation], the licensee did not comply with the section cited above in cribs and playpens were completely covered with blanket covers, which covered top and sides of cribs and playpen, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/11/2024
Plan of Correction
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2
3
4
Licensee will no longer cover tops or sides of cribs and playpens with blanket covers. Licensee will remove covers from home.
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: 10/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2024


LIC809 (FAS) - (06/04)
Page: 7 of 11
Document Has Been Signed on 10/10/2024 08:00 PM - It Cannot Be Edited


Created By: Maria Olguin-Leon On 10/10/2024 at 04:32 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: ROSALES, ROSALVA
FACILITY NUMBER: 414004153

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above in 4 out of 4 infants did not have 15 minute sleep logs, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2024
Plan of Correction
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2
3
4
Licensee will keep sleeping logs for all infants under 24 months. Licensee will email sleeping logs to LPA by POC date.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in S3 has not completed mandated reporter training, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2024
Plan of Correction
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2
3
4
S3 will complete mandated reporter training by POC date and email completion certificate to LPA.
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: 10/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2024


LIC809 (FAS) - (06/04)
Page: 8 of 11
Document Has Been Signed on 10/10/2024 08:00 PM - It Cannot Be Edited


Created By: Maria Olguin-Leon On 10/10/2024 at 04:32 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: ROSALES, ROSALVA
FACILITY NUMBER: 414004153

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above in S3 has not completed CPR/First aid training and was left alone with children, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2024
Plan of Correction
1
2
3
4
S3 will register and complete CPR/First Aid training by POC date. Licensee will email LPA copy of S3's completed certificate.
Type B
Section Cited
CCR
102416.1(d)
Personnel Records
(d) All personnel records shall be maintained at the child care home and shall be available to the licensing agency for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above in S3 did not have a personnel file available for review, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2024
Plan of Correction
1
2
3
4
Licensee will collect required licensing form for S3 for staff file, Licensee will email LPA photos of documents completed for staff file.
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: 10/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2024


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