414004550-9-29-2021-05-CC-LTMO-C7BV5W-20210929160835

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414004550
Report Date: 09/29/2021
Date Signed: 09/29/2021 04:12:41 PM

Document Has Been Signed on 09/29/2021 04:12 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:	GONZALEZ, KAREN F.		FACILITY NUMBER:	414004550
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	09/29/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	KAREN GONZALEZ		TIME COMPLETED:	02:05 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At 10:30 AM, Licensing Program Analyst (LPA) Tapia-Mandujano conducted an unannounced Annual Required inspection. LPA met with Licensee, Karen Gonzalez and explained purpose of inspection. Present in home were the Licensee, Licensee’s assistant and 5 enrolled children (2 infants and 3 preschool age). Licensee is operating within capacity requirements on this day. All adults living and/or working in the home have a criminal record clearance on file. Licensee rents home, which is a 3 bedroom, 1 bathroom, single level house with an In-Law unit and converted garage (playroom). Hours of operation are Monday to Friday from 8am to 6pm. Daycare area is: Living Room, Dining area, Converted Garage, Bathroom (in Converted Garage), ‘concrete Patio’ and ‘Grass’ backyard. OFF limit areas: Kitchen, Laundry area, All bedrooms, bathroom (inside the house), and In-Law unit(in the backyard). All off limit areas, including all closets, are properly barricaded. LPA inspected the home for health and safety hazards. LPA observed home to be in good repair with proper temperature and ventilation. There were a variety of age appropriate toys and equipment in the home which were in good condition. Home has a fireplace in the living room that is properly barricaded. All cleaning supplies, poisons and other chemicals were stored inaccessible to children behind child safety locked cabinets. There was a working smoke detector and carbon monoxide detector, a fully charged fire extinguisher, and a working telephone. Phone number listed for Licensee is current. Per Licensee, there are no weapons or firearms in the home. Per licensee, sick children are isolated in the living room. There were no pools, spas or bodies of water on the property. Backyard area is enclosed with an least 4ft high fence. Outdoor toys and equipment in the backyard were age appropriate and in good repair. LPA reviewed children and assistant records. Licensee's Pediatric First Aid/CPR expires on 07/2023. Last emergency drill was conducted in July 29th, 2021. Emergency drills are conducted at least once every six months and are properly logged. Continued on Page 2...

SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021

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: GONZALEZ, KAREN F.	FACILITY NUMBER: 414004550
	VISIT DATE: 09/29/2021

NARRATIVE

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Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: www.ada.gov/childqanda.htm.

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 tools, please send them by email 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 reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 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 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. 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.

Deficiencies were cited today under CCR, Title 22, Div. 12, Chapt. 1. Please refer to LIC 809D for details.

A notice of site visit was given and must remain posted for 30 days.

An exit interview conducted and report was reviewed with the licensee, Karen Gonzalez.

SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021

LIC809 (FAS) - (06/04)

Page: 2 of 9

Document Has Been Signed on 09/29/2021 04:12 PM - It Cannot Be Edited

Created By: Leslit Tapia-Mandujano On 09/29/2021 at 01:08 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: GONZALEZ, KAREN F.	FACILITY NUMBER: 414004550
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/29/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1597.622(c)

Administration of Child Day Care Licensing

(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home. 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 by not maintaining a copy of immunizations that are required for assistant which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/06/2021
	Plan of Correction
1 2 3 4	Licensee will send a copy of immunizations for assistant via email to LPA by 10/06/21 and keep a copy of immunizations in assistants' file.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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:

Cindy Interiano

LICENSING EVALUATOR NAME:

Leslit Tapia-Mandujano

LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021

LIC809 (FAS) - (06/04)

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