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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004696
Report Date: 07/13/2022
Date Signed: 07/13/2022 01:51:24 PM

Document Has Been Signed on 07/13/2022 01:51 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:GONZALEZ, MARY NOKOMFACILITY NUMBER:
414004696
ADMINISTRATOR:GONZALEZ, MARY NOKOMFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 312-1208
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 12DATE:
07/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Mary Nokom GonzalezTIME COMPLETED:
02:00 PM
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On July 13, 2022 at approximately 11:20am, Licensing Program Analyst (LPA) Catrina Quimbo conducted an unannounced, annual inspection. LPA met with staff member, A1, and explained the purpose of the inspection. At start of LPA's visit, licensee was not present in the home. LPA advised A1 to alert licensee of LPA's presence.

Present in the home included 12 enrolled children (all preschool age), A1 and A2. All adults working in the home have fingerprint clearance on file and are associated to facility. Facility is operating within capacity limits and ratios at time of LPA's visit. Per A2, program operates with children ages 2 years to 4 years old. Hours of operation are 8:00am to 5:00pm.

At approximately 11:30am, LPA conducted a health and safety inspection inside and outside the home. The home is a single level home that consists of two bedrooms, one bathroom, living room, dining area, kitchen, and side yard/driveway, backyard area and detached garage. The DAY CARE AREAS are the living room (main classroom), bedroom#1 (second classroom), dining area, bathroom#1 and backyard area. The OFF-LIMITS AREAS are bedroom #2, kitchen, side yard/driveway and detached garage. All off limit areas are made inaccessible to children by child safety gates and/or locked doors.

Facility operates as a Montessori program. LPA observed home to have age appropriate equipment and toys. All cleaning supplies, poisons and other chemicals were stored inaccessible to children behind child safety locked cabinets or located in an off limit area.

At approximately 12:00pm, Licensee arrived to facility. LPA did not observe any pools, spas or bodies of water on the property. The entire backyard is enclosed with an at least 5ft high fence. Backyard is equipped with appropriate outdoor toys that were in good working condition. Backyard is shared by a separate licensed provider. Per licensee, children do not co-mingle with separate licensed provider's enrolled children.
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SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2022
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, MARY NOKOM
FACILITY NUMBER: 414004696
VISIT DATE: 07/13/2022
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There was a working smoke detector and carbon monoxide detector, a fully charged fire extinguisher 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 ten children’s records which were complete. Children’s files have a record of emergency identification information on file. LPA reviewed licensee, A1 and A2's files. Required immunizations were made available for review. A1 has a valid CPR certificate that will expire 06/2023. Licensee's CPR has expired as of 05/2022. Per licensee, renewed course has been completed. Licensee to provide LPA proof of completed, renewed course by 07/22/2022. Last emergency drill was conducted 05/11/2022. Emergency drills are conducted at least once every six months and are properly logged.

During Inspection:
- Licensee was given information regarding PIN 20-24-CCP Safe Sleep Regulation and Lead Poisoning Facts Flyer.
-Licensee was reminded, as of September 1, 2016, all Staff and Volunteers must provide proof of immunization against pertussis, measles, and influenza, or qualifies for an exemption, pursuant to Health and Safety code 1596.7995 and 1597.622.
-Licensee was reminded about Mandated Reporter training available on CCLD website. Training must be completed every 2 years by all staff hired. Training can be taken online at www.mandatedreporterca.com.
-Licensee was reminded about the Provider Information Notices (PINs) on CCLD website.

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/process

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SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022
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, MARY NOKOM
FACILITY NUMBER: 414004696
VISIT DATE: 07/13/2022
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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.

An exit interview conducted and report was reviewed with the licensee, Mary Nokom Gonzalez.
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022
LIC809 (FAS) - (06/04)
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