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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004831
Report Date: 08/14/2024
Date Signed: 08/14/2024 12:03:51 PM

Document Has Been Signed on 08/14/2024 12:03 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:ESPINOSA, ALEJANDRAFACILITY NUMBER:
414004831
ADMINISTRATOR/
DIRECTOR:		ESPINOSA, ALEJANDRAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 283-5526
CITY:MENLO PARKSTATE: CAZIP CODE:
94025
CAPACITY: 14TOTAL ENROLLED CHILDREN: 10CENSUS: 10DATE:
08/14/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Alejandra EspinosaTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On August 14th, 2024, Licensing Program Analysts (LPAs) Kassandra Medrano and Diana Alavarado conducted an annual required inspection which included a tour of the home and yard, and a review of the required day-care forms with the licensee. Present in the home is Licensee, 10 children (3 infants and 7 preschool aged) and 2 adult assistants, Ana Cruz and Johanna Valenzuela.
During inspection it was found that capacity and ratio requirements of children were observed in compliance today. OFF LIMIT AREAS: Front yard, Bedroom 2, and side yard. During todays inspection licensee stated that kitchen is only used by children to pass through to yard. Adults living in the home are Licensee, and Husband, Kyrk "Justin" Lawyer. A review of records indicates that all adults working or living in the home who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. 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. During review of documents it was stated that the last emergency drill was conducted 12/2023 and was not logged. The day-care operates 8am-5pm, Monday-Friday. LPA observed the following: No baby walkers, bouncers, exercausers, etc. allowed to be used during day-care hours. Home has proper lighting and ventilation. Home has a working telephone, a working smoke and carbon monoxide detector, and a fully charged 2A10BC fire extinguisher. Licensee stated that there are no bodies of water on the property, and facility was inspected and no bodies of water were found. Licensee states there are no guns or weapons of any kind in the home. During review of files, Licensee’s and helper Johanna's CPR and First Aid expires on 8/2025. Licensee provides daily snacks and lunch. Isolation of sick children reviewed/discussed. During file reviews it was observed that files were incomplete. 3 children's files were missing documentation of immunization's as well as 3/3 infants were missing sleeping logs. As well as staff files were missing documentation of immunization's.
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SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Kassandra Medrano
LICENSING EVALUATOR SIGNATURE: DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2024
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 08/14/2024 12:03 PM - It Cannot Be Edited


Created By: Kassandra Medrano On 08/14/2024 at 10:51 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: ESPINOSA, ALEJANDRA
FACILITY NUMBER: 414004831

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2/2 staff were missing documentation of immunizations which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2024
Plan of Correction
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Licensee to send documentation of immunizations
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

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 3/3 infants were missing sleeping logs which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2024
Plan of Correction
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Licensee to send documentation of logs to LPA
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:Kassandra Medrano
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024


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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: ESPINOSA, ALEJANDRA
FACILITY NUMBER: 414004831
VISIT DATE: 08/14/2024
NARRATIVE
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 Licensee was reminded that time outs cannot be any longer than one minute per age of the child and cannot exceed five minutes. Licensee stated that they practice "thinking time" and each child completes 5 minutes. LPAs spoke to licensee and staff about intended use of items such as high chairs and as well as an outdoor play pen. Licensee understands that care cannot be provided for more than the capacity as stated on the license. Requirements for reporting suspected child abuse was discussed, as well as reporting requirements for unusual incidences. All required postings are properly posted (License/Parent’s Rights poster/Emergency Disaster Plan and Earthquake Preparedness Checklist) Licensee was reminded that as of September 1, 2016, a person may not be employed or volunteer at a childcare facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and1597.662. Licensee was informed about the Provider Information Notices (PINs) on CCLD website. Licensee was reminded about Mandated Reporter Training available on CCLD website (www.ccld.ca.gov or www.mandatedreporterca.com). 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. 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. 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/. This report and appeal rights were discussed with Licensee. This report must be available in the facility for public review. 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.
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SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Kassandra Medrano
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
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: ESPINOSA, ALEJANDRA
FACILITY NUMBER: 414004831
VISIT DATE: 08/14/2024
NARRATIVE
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During the exit interview, the licensee, Alejandra, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS,.Exit interview conducted and report was reviewed with the licensee.

California Code of Regulations, Title 22 deficiencies are being cited on the following page(s):
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Kassandra Medrano
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 08/14/2024 12:03 PM - It Cannot Be Edited


Created By: Kassandra Medrano On 08/14/2024 at 11:42 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: ESPINOSA, ALEJANDRA
FACILITY NUMBER: 414004831

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on iinterview and record review, the licensee did not comply with the section cited above in 3/10 children were missing documentation of immunizations which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2024
Plan of Correction
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Licensee to send documentation of immunizations of the three children
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:Ali Zebila
LICENSING EVALUATOR NAME:Kassandra Medrano
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024


LIC809 (FAS) - (06/04)
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