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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004674
Report Date: 01/09/2024
Date Signed: 01/09/2024 12:51:27 PM

Document Has Been Signed on 01/09/2024 12:51 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:HERNANDEZ,MARILU V.FACILITY NUMBER:
414004674
ADMINISTRATOR:HERNANDEZ, MARILU V.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 773-8427
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94063
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 12DATE:
01/09/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Licensee, Marilu HernandezTIME COMPLETED:
01:00 PM
NARRATIVE
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On January 9th, 2024, Licensing Program Analysts (LPAs) Tapia-Mandujano and Gil conducted an unannounced, plan of correction (POC) visit. LPAs were granted entrance by licensee, Marilu Hernandez and explained the purpose of the visit. Present during inspection were Licensee and two assistant supervising 12 children (4 infants and 8 preschoolers). Facility is operating within capacity limits on this day. Not all adults living and working in the home have fingerprint clearance and are associated to the facility.

On December 18, 2023, LPA Tapia-Mandujano arrived at the facility to conduct a complaint investigation. During the inspection, LPA determined facility had been operating over capacity with 4 infants and 9 preschool age children. LPA issued a Type A citation for operating over licensed capacity limits. A POC was developed with licensee. As well as capacity limits were explained to licensee.

During today's inspection, LPAs observed Notice of Site Visit posted with Type A reports from 12/18/23, as well as observed that parents signed LIC 9224 'Acknowledgment of of Receipt of Licensing Reports'. As of this date, LPAs observed the deficiency for over capacity was cleared.

As LPAs were doing the walk through, Guardian Roster was checked and LPAs observed there was an adult working in the facility that did fingerprints but it has not cleared. Please refer to LIC 809D for Type A deficiency. Civil penalties were assessed.

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

Exit interview conducted and report was reviewed and translated to Spanish by LPA Tapia-Mandujano with the licensee, Marilu V. Hernandez.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2023
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
Document Has Been Signed on 01/09/2024 12:51 PM - It Cannot Be Edited


Created By: Leslit Tapia-Mandujano On 01/09/2024 at 12:28 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: HERNANDEZ,MARILU V.
FACILITY NUMBER: 414004674

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/10/2024
Section Cited
CCR
102370(d)

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102370(d): Criminal Record Clearance: "All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:"

This requirement is not met as evidenced by:
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At approximately 12:15pm, LPAs observed assistant leave the facility.
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Based on observation and record review, the licensee did not comply with the section cited above as there is an assistant who has not cleared fingerprints that is caring for children in care which poses an immediate health, safety or personal rights risk to persons in care.
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Licensee will have individual get refingerprinted and ensure assistant is cleared prior to returning to care for children in care.

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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:Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024


LIC809 (FAS) - (06/04)
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