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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004793
Report Date: 06/18/2021
Date Signed: 06/22/2021 02:30:13 PM

Document Has Been Signed on 06/22/2021 02:30 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:COIMBRA, TALITA MIRELLEFACILITY NUMBER:
414004793
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
06/18/2021
TYPE OF VISIT:POCANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Talita CoimbraTIME COMPLETED:
09:00 AM
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Due to COVID-19 and DPH guidelines of social distancing, Licensing Program Analyst (LPA) Catrina Quimbo conducted the Plan of Correction tele-inspection via FaceTime on June 18, 2021 at 8:25am with licensee, Talita Coimbra. Licensee is currently licensed at 162 36th Avenue, San Mateo, Ca 94403 (Fac#414004744). Licensee applied for a relocation 05/03/2021. A plan of correction inspection was conducted inside the home.

LPA observed off-limit areas in home to have child proof knobs and/or child safety gates. Laundry room, Bedroom #1, Bedroom #2, Bedroom #3, Closet hallway located on second level of home all have child proof knobs located on door handles. LPA observed an extended child safety gate in backyard area of home. Entire backyard area is enclosed with an least 5ft high fence. Half of backyard area is cushioned with artificial turf. The other half of backyard area contains concrete, wood chips and rocks. LPA observed the extension of child safety gate to separate artificial turf area and concrete with wood chips and rocks area. Backyard area with concrete, wood chips and rocks is OFF-LIMITS. Age appropriate materials in bathroom #1 are offered to children in care.

Based on today’s inspection, licensee is recommended for licensure. As of 6/18/2021, the current licensed located 162 36th Avenue, San Mateo, Ca 94403 (Fac#414004744) is forfeited. This report is public and can be reviewed. A copy of this report will be emailed to licensee. Licensee was advised to acknowledge receipt of report once received.

SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2021
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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