414004696-12-15-2023-05-CC-JTSE-CYJUN8-20231215144330

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414004696
Report Date: 12/15/2023
Date Signed: 12/15/2023 02:44:19 PM

Document Has Been Signed on 12/15/2023 02:44 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:	GONZALEZ, MARY NOKOM		FACILITY NUMBER:	414004696
ADMINISTRATOR:	GONZALEZ, MARY NOKOM		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(650) 312-1208
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94403
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 5	DATE:	12/15/2023
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Licensee, Mary Gonzalez		TIME COMPLETED:	02:55 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 12/15/2023, at approximately 11:20AM, Licensing Program Analyst (LPA) Jonathan Tse conducted an unannounced annual visit at the facility. LPA was granted entry to the facility by H1, Annabel Guevara. LPA explained the purpose of the visit. Licensee Mary Gonzalez arrived at 11:40AM. Present during the visit was Licensee, two helpers (H1 and H2), and five preschool age children. The facility is in compliance with capacity requirements on this day. The facility enrolls children ages two and up. Operating hours are from 8:30AM to 5:00PM, Monday to Friday. The facility is a single-level, two-bedroom, one-bathroom home. Daycare Areas: Living Room, Bedroom #1 (converted into classroom), Dining Area, Bathroom, and Backyard. Off-limits Areas: Bedroom #2, Kitchen, Driveway, and Garage. LPA inspected the home for any health and safety hazards. LPA observed the home to be in clean and orderly condition. There are age-appropriate toys, equipment and learning materials in the Living Room, Bedroom #1, and the Dining Area. The home is equipped with a fully charged 2A10BC fire extinguisher. There is a carbon monoxide detector present in the home. There is a fire alarm system running throughout the home. LPA observed the first aid kit to be fully equipped. All cleaning supplies, poisons, and other chemicals are secured with childproof locks or barriers. All off-limits areas are secured with childproof doorknobs or barriers. Per Licensee, there are no firearms present in the home. LPA observed the Backyard to be clean and free of debris and other loose articles. The facility shares usage of the Backyard with another facility. They use the Backyard in shifts so that there is no co-mingling of children from different licensed facilities. The Backyard is enclosed by a fence that is at least five feet high. There are no pools or other bodies of water present in the facility. Continued on Page Two

SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

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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Document Has Been Signed on 12/15/2023 02:44 PM - It Cannot Be Edited

Created By: Jonathan Tse On 12/15/2023 at 01:07 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, MARY NOKOM	FACILITY NUMBER: 414004696
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1596.871(c)(1)(A)

Administration of Child Day Care Licensing

Subsequent to initial licensure, a person specified in subdivision (b) who is not exempt from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification, pursuant to subdivision (f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in one out of three personnel present at the facility which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/18/2023
	Plan of Correction
1 2 3 4	Licensee shall have H2 fingerprinted and submit proof of completion to LPA by set due date.

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:

Ali Zebila

LICENSING EVALUATOR NAME:

Jonathan Tse

LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: GONZALEZ, MARY NOKOM	FACILITY NUMBER: 414004696
	VISIT DATE: 12/15/2023

NARRATIVE

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Page Two
LPA reviewed three personnel files and four children’s files. Through record review of the facility’s Guardian roster, LPA observed that H2 did not have fingerprint clearance or association to the facility. LPA notified Licensee, who asked H2 to leave the facility until they got fingerprinted. H2 complied with the request. Licensee’s Mandated Reporter Training expires 11/2025. Licensee did not have proof of First Aid/CPR certification at the time of the visit and will send proof to LPA. LPA advised Licensee to ensure that all staff complete their First Aid/CPR certification from the American Heart Association, American Red Cross, or a vendor that is EMSA certified.

LPA observed children’s files to all include Emergency and Identification Information (LIC700) and Consent for Emergency Medical Treatment (LIC627). LPA advised that all children’s files should contain a signed copy of the Notification of Parents’ Rights (LIC995A).

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 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.

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-andresources/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.
Continued on Page Three

SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: GONZALEZ, MARY NOKOM	FACILITY NUMBER: 414004696
	VISIT DATE: 12/15/2023

NARRATIVE

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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/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

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

See LIC809-D for Type-A deficiency cited today. LPA advised that LIC9224 must be provided to all parents and maintained in all children's files for one year after a Type-A deficiency is issued.
See LIC9102-TV for Technical Violations issued today.
See LIC9102-TA for Technical Assistance provided today.

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

Exit interview conducted and report was reviewed with the Licensee, Mary Gonzalez.

SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

LIC809 (FAS) - (06/04)

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