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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004696
Report Date: 11/08/2024
Date Signed: 11/08/2024 10:52:06 AM

Document Has Been Signed on 11/08/2024 10:52 AM - 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 NOKOMFACILITY NUMBER:
414004696
ADMINISTRATOR/
DIRECTOR:		GONZALEZ, MARY NOKOMFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 312-1208
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
11/08/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Nova Marie MatalaTIME VISIT/
INSPECTION COMPLETED:
11:20 AM
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On November 8th, 2024, at approximately 9:15 AM, Licensing Program Analyst (LPA) Janet Gil conducted an unannounced, annual inspection. LPA met with licensee's present assistant, Nova Marie Matala(A1), and explained the purpose of the inspection. Present during LPA’s visit included two assistants(A1 and A2), and 8 enrolled children (1 infant and 7 preschoolers). Per A1, licensee was away for a personal appointment at the time of inspection. The licensee is a large license and is operating within capacity limits and ratio.

Licensee owns home, which is a 2 bedrooms, 1 bathroom, single level home. Licensee lives in home. All adults living and working in the home have fingerprint clearance. Facility operates Monday Through Friday 8:30 AM to 5:00 PM.

Day Care Areas: Living Room, Bedroom #1 (converted into classroom), Dining Area, Bathroom, and Backyard.

Off Limit Areas: Bedroom #2, Kitchen, Driveway, and Garage.

At approximately 9:40 AM, LPA toured day care areas of home with A1. LPA observed the home to be in repair with proper temperature and ventilation. Home is equipped with a variety of toys and materials that were observed to be in working condition. LPA observed a fully stocked accessible first aid kit located in the closet near Bedroom #1. LPA did not observe any accessible cleaning supplies, poisons, and solutions in day care areas. LPA observed electrical outlets to be made inaccessible with furniture. Home is equipped with a fully charged fire extinguisher and multiple smoke and carbon monoxide detectors. LPA tested carbon monoxide detector in hallway area near Day Care Bathroom, which was observed to be working. Licensee does not have any children in care with allergies or IMS plans. Per A1, home facility provides all foods for the children in care.

At approximately 10:00 AM, LPA observed bathroom for children's use was in proper working condition. LPA observed bathroom to include appropriate toileting equipment and sanitation products. LPA did not observe any hazardous materials to be accessible to children in the bathroom.

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SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Janet Gil
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: 11/08/2024
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The entire backyard is fully enclosed. The outdoor area is equipped with a variety of toys and materials. LPA did not observe any pools, spas, or bodies of water in day care areas.

LPA reviewed six children records which were complete. The children’s files have a record of emergency identification information and required immunization. LPA reviewed staff records for A1 and A2 which were complete. A1's CPR/FIrst Aid is current and will expire 10/2025. The licensee’s Mandated Reporter training certification is also current for both assistants. Both present assistants also has required immunization available for review.

Licensee has licensing documentation properly posted and available for review. The licensee also maintains a childcare roster that was made available for review. Emergency disaster drills have not been conducted at least once every six months. The last disaster drill was conducted on March of 2024. A1 was reminded that all drills must be conducted within in 6 months. Type B deficiency is being issued on this day in accordance with the California Code of Regulations, Title 22, see LIC 809D. Per A1, there are no weapons or firearms in the home.

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.

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SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Janet Gil
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024
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: 11/08/2024
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LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage athttps://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.

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 childcare by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

On this date, 11/5/2024, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

During the exit interview, A1, Nova Marie Matala, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Type B deficiency is being issued on this day in accordance with the California Code of Regulations, Title 22, see LIC 809D.

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


Exit interview conducted and report was reviewed with A1, Nova Marie Matala.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Janet Gil
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/08/2024 10:52 AM - It Cannot Be Edited


Created By: Janet Gil On 11/08/2024 at 10:36 AM
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: 11/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in conducting documenting fire drills each month which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2024
Plan of Correction
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A1 plans to conduct drill and document it, then send documentation to LPA Gil via email within the next week.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Garfield Leung
LICENSING EVALUATOR NAME:Janet Gil
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2024


LIC809 (FAS) - (06/04)
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