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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004855
Report Date: 10/13/2023
Date Signed: 10/13/2023 12:47:01 PM

Document Has Been Signed on 10/13/2023 12:47 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:GONCALVES DE SOUZA, ELEANDRAFACILITY NUMBER:
414004855
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 8DATE:
10/13/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Eleandra Goncalves de SouzaTIME COMPLETED:
12:50 PM
NARRATIVE
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On 10/13/2023 at 9:20AM., Licensing Program Analysts (LPA), Luis J. Gomez met with Licensee, Eleandra Goncalves de Souza. Purpose of inspection was explained and was for an Unannounced; Case Management inspection for Increase of Capacity. Present was the licensee and helper caring for 8 child (4 infant-age, 4 preschool age). Adults have criminal record clearances on file. Licensees home is a 2 bedroom, 2 bathroom, 2 level townhouse. Day and hours of operation are: Monday – Friday 7:30A.M. – 5:30P.M. Day-care Area: Lower Level: Playroom #1, Living Room; Bathroom #1; Hallway (Pass Through Only) and Outdoor Play Area. Off-limit Area: Lower Level: Kitchen, Garage, Upper Level: Bedroom #1, Bedroom #2 and Bathroom #3. LPA inspected entire home, Inside and outside, with applicant for health and safety hazards.

At 9:35AM., the following was observed: Facility was clean, orderly, with age-appropriate playthings and materials available for the children. Furniture, toys and books inspected were in proper repair. Storage is located in entry way, for children belongings. The off-limit areas have been made inaccessible with child safety gates. Licensee has child size tables and chairs for seated activities. Bathroom #1 was clean, with fixtures in operating condition. Diaper changing table is available in playroom. Fireplace in playroom has been barricade. For napping services, LPA observed several mats and cribs stored in the playroom. Infant cribs were equipped with tight-fitting sheet and proper size mattress. Detergents; toxins; cleaning compounds; and items (which could pose a danger) are stored in the off-limit areas. Facility has sufficient ventilation and lighting. Facility has a functioning cell phone, smoke/ carbon monoxide combination detector and fire extinguisher (2A10BC).



At 9:50AM., LPA inspected the outdoor play area (Patio). Outdoor Area was completely enclosed, with playthings in good repair. Soft turf has been installed for added safety. Home did not have pools, fishponds, spas, jacuzzi or any other bodies of water. (REFER TO 809C, FOR CONT.)
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2023
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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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: GONCALVES DE SOUZA, ELEANDRA
FACILITY NUMBER: 414004855
VISIT DATE: 10/13/2023
NARRATIVE
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(PAGE 2)
At 10:05AM., LPA reviewed facility records, including 8 children’s files and 1 personnel record. Children records included the: Health History (LIC702) and Identification and Emergency Information (LIC700).

At 10:30AM., Based on record review, observations and interview, LPA confirmed licensee is operating over capacity with 8 children, 4 infants in care.

At 10:45AM., Based on record review, LPA confirmed children’s immunization records missing from facility files.

At 10:50AM, Based on record review and interview, LPA confirmed licensee is not documenting napping conditions, every 15 for each infant in care.

Personnel records included the: Notice of Employee Rights (LIC9052); Updated Mandated Reporter Training Certification (AB1207); and Statement Acknowledging Requirement to Report Suspected Child Abuse (LIC9108).

LPA reminded licensee to ensure staff proof of immunization are stored in facility files. Advisory Note: Technical Violation (LIC9102TV) was issued.

Licensee’s Cardiopulmonary Resuscitation / First Aid certification is current, expiring on: 8/ 2025.
Licensee’s Mandated Reporter Training Certification (AB1207) is current, expiring on: 1/8/2024.

Per Licensee, she will provide daily snacks and meals. Isolation of an ill child will be in playroom. Per licensee, home does not have any firearms or weapons. Licensee has a pet cat.

Per licensee, last fire drill was conducted on 10/2/2023 and was properly logged.

Required forms are posted in entry way include the: Facility License; Notification of Parent’s Rights (PUB294); Earthquake Preparedness Checklist; and Emergency Disaster Plan (LIC610A).

Capacity worksheet resource was reviewed with licensee during inspection. Copy of resource was provided.

Licensee was informed that the Department must be notified prior to the use of designated off-limits areas. LPA and the licensee discussed licensing regulations and the capacity requirements. Any children under 10 years of age will be counted in the capacity. (REFER TO 809C, FOR CONT.)
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023
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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: GONCALVES DE SOUZA, ELEANDRA
FACILITY NUMBER: 414004855
VISIT DATE: 10/13/2023
NARRATIVE
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(Page 3)
Licensee was advised that all food containers brought from home must be properly stored and labeled. Licensee understands the required emergency disaster drills are to be conducted and documented every six months. Licensee understands that the use baby walkers, bouncers, jumpers and similar items are not to be used for children in care. Smoking is prohibited inside a Family Childcare Home.

Licensee was informed 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 for influenza, pertussis and measles or qualifies for an exemption pursuant to Health and Safety Code 1596.7995 and 1597.662.



Licensee was reminded that all adults 18 years and over living in the home, person who provides care and supervision to children, and staff who have contact with children, including employee and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain criminal 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.

The licensee provided proof of control of property and because licensee rents/ leases home, proof of landlord notification is required. The licensee obtained a signed Property Owner/ Landlords Consent form (LIC9149).
LPA discussed the safe sleep regulations with licensee and discussed Child Care Licensing Safe Sleep Web page at:https://www.cdss.ca.gov/inforesource/child-care-licesning/public-information-and-resources/safe-sleep as an additional resource. LPA informed licensee of the importance of checking for recalled infant devices on United States consumer Product Safety Commission (CPSC) website at http://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Prior to recommendation for approval of Increase in Capacity, licensee must complete the following:
1.Clear deficiencies issued during inspection.

(Refer to 809C, for CONT.)
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/13/2023 12:47 PM - It Cannot Be Edited


Created By: Luis Gomez On 10/13/2023 at 11:31 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: GONCALVES DE SOUZA, ELEANDRA
FACILITY NUMBER: 414004855

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/16/2023
Section Cited
CCR
102416.5(a)

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102416.5(a) Staffing Ratio and Capacity. The capacity specified on the license shall be the maximum number of children for whom care may be provided at any one time. This requirement is not met as evidenced by:
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Licensee has pending application for large capacity licensure. Plan for correction, and signed LIC9224, Notice of A-type deficiency forms, must be completed by due date: 10/16/2023.
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At 10:30AM., Based on record review, observations and interview, LPA confirmed licensee is operating over capacity with 8 children, 4 infants in care. This poses an immediate health and safety risk to children in care.
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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:Marie Rodriguez
LICENSING EVALUATOR NAME:Luis Gomez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/13/2023 12:47 PM - It Cannot Be Edited


Created By: Luis Gomez On 10/13/2023 at 11:44 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: GONCALVES DE SOUZA, ELEANDRA
FACILITY NUMBER: 414004855

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/16/2023
Section Cited
CCR
102425(j)(2)(D)

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102425(j)(2)(D) Infant Safe Sleep: Provider shall supervise infants while they are sleeping and adhere to the following requirements: Documentation shall be maintained in the infants files and available to the department for review. Document shall include the following: a. date b. infants name. c. time of each 15 minute check. This requirement was not met as evidenced by:
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Licensee will begin documenting infant napping conditions every 15 minutes.

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At 10:50AM, Based on record review and interview, LPA confirmed licensee is not documenting napping conditions, every 15 for each infant in care. This poses a potential health and safety risk to children in care.
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Proof of correction will be submitted via email to the Department by the due date: 10/16/2023.
Type B
10/16/2023
Section Cited
CCR102418(a)

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102418(a) Immunization 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 was not met as evidenced by:
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Licensee will ensure children's immunization records are stored in the facility file by the due date: 10/16/2023.
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At 10:45AM., Based on record review, LPA confirmed children’s immunization records missing from facility files. This poses a potential health and safety risk to children in care.
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Proof of correction will be submitted to the Department via email.
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:Marie Rodriguez
LICENSING EVALUATOR NAME:Luis Gomez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2023


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: GONCALVES DE SOUZA, ELEANDRA
FACILITY NUMBER: 414004855
VISIT DATE: 10/13/2023
NARRATIVE
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Type “A” violation was issued today. Licensee was advised to provide a copy of the Evaluation Report and all Type “A” Deficiencies cited, to parents and guardians of children currently enrolled in care and to parents of newly enrolled children during the next 12 months. A signed and dated LIC 9224 (Deficiency and Acknowledgment of Receipt of Licensing Reports) shall be maintained in all children's files.

Based on today's inspection, deficiencies were observed in areas evaluated according to California Title 22, Div. 12 Chap. 3 Health and Safety Code of Regulations and cited on 809D. LPA conducted exit interview, appeal rights, plan of correction, report was reviewed with licensee, Eleandra Goncales de Souza. Licensee’s signature of this form acknowledges receipt of these documents.

Notice of Site Visit was provided and must remain posted for 30 days.



Exit interview was conducted and report was reviewed with Licensee, Eleandra Goncalves de Souza. Copy of report was provided to licensee. This report will be kept in facility file and made available for public review upon request. Desk Duty is available Monday- Friday between 8AM - 5PM at (650) 266 -8800.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023
LIC809 (FAS) - (06/04)
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