<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004550
Report Date: 10/20/2022
Date Signed: 10/20/2022 01:48:47 PM

Document Has Been Signed on 10/20/2022 01:48 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: 8TOTAL ENROLLED CHILDREN: 5CENSUS: 5DATE:
10/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Assistant, Reyna ElizabethTIME COMPLETED:
02:15 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
On October 20th, 2022 at approximately 12:20PM, Licensing Program Analyst(LPA) Tapia-Mandujano conducted a Required Annual unannounced inspection at facility and met with assistant, Reina Lopez. Licensee, Karen Gonzalez arrived shortly after. Purpose of the inspection was explained. Present in the home is assistant and licensee caring for 5 children (3 infant and 2 preschool age). All adults living and working in the home are fingerprint cleared and associated.

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 .All off limit areas are properly barricaded.

LPA toured day care areas of home with Licensee to inspect for health and safety hazards. LPA observed home to be clean and 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 that is properly barricaded. There are no pools, and bodies of water in the premises. Licensee has pet dog. All cleaning supplies, poisons and other chemicals were stored inaccessible to children. Discipline Policy was discussed. Isolation for sick child will be in the living room area inside the home.

There was a fully charged fire extinguisher, smoke alarm and carbon monoxide alarm, and a working telephone on site. Phone number listed for Licensee is current. Per Licensee, there are no weapons or firearms in the home. LPA reviewed five children's record. LPA also reviewed facility and personnel records. Licensees CPR & First Aid Certificate will expire 07/2023. Mandated Reporter certificate will expire on 10/2023. Emergency drills must be conducted at least once every six months and should be properly logged. Last emergency drill was conducted on 04/2022.

Continued on Page 2...
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2022
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 2
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: 10/20/2022
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
26
27
28
29
30
31
32
Page 2 Continued...

Incidental Medical Services (IMS) policy was discussed. Licensee does not offer IMS at this time. Licensee has an IMS planned developed and on file with the department. 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/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.

No deficiencies were cited today under CCR, Title 22, Div. 12, Chapt. 1.

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

Exit interview conducted and report was reviewed with licensee, Karen Gonzalez.
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2