414004855-11-13-2023-05-CC-LGOZ-CXK2TR-20231113164110

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414004855
Report Date: 11/13/2023
Date Signed: 11/13/2023 04:41:29 PM

Document Has Been Signed on 11/13/2023 04:41 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, ELEANDRA		FACILITY NUMBER:	414004855
ADMINISTRATOR:	GONCALVES DE SOUZA, ELEAND		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(415) 573-6043
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94402
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 7	DATE:	11/13/2023
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Eleandra Goncalves de Souza		TIME COMPLETED:	04:45 PM

NARRATIVE

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On 11/13/2023 at 2:10PM., Licensing Program Analysts (LPA), Luis J. Gomez, Yasha Nasiripour met with Licensee, Eleandra Goncalves de Souza. Purpose of the inspection was explained and was for an Unannounced; Annual Random. Present was the licensee and helper, caring for 7 children (3 infant-age, 4 Preschool- age). Adults have criminal record clearances on file. Licensee’s home is a 2 bedroom, 2 bathroom 2 level townhouse. Days and hours of operation are Monday- Friday, 7:30AM- 5:30PM. Daycare areas: Lower Level: Living room (Playroom); Hallway (Pass through only); Bathroom #1; and Outdoor play Area. Off Limit areas: Lower Level: Kitchen, Garage and Entire Upper Level. LPA inspected home, inside and outside, with licensee for health and safety hazards.

At 2:13PM., the following was observed: Facility was clean, orderly, with age-appropriate playthings available for the children. Fireplace has been properly barricaded. Floor/ground surfaces was clear of obstructions or potential hazards. Off-limit areas have been properly barricaded. Furniture, toys, and books inspected were in good repair. LPAs observed several cubbies for storage of children’s belongings. Playroom has child sized tables and chairs for seated activities. For scheduled napping services, LPAs observed several play pens with tight-fitting sheets. Licensee has available for each infant in care. Per licensee, play pens are equipped with tight-fitting sheet.

At 2:15PM., Based on observations, LPAs confirmed infant inside napping crib while awake.

LPA reminded licensee to ensure all loose blankets inside infant cribs are removed. Advisory Note: Technical Violation (LIC9102) was issued.

Bathroom #1 was clean, with adequate supplies for hand washing. Facility was the proper temperature, with ventilation and lighting. Home had functioning telephone service; smoke/ carbon monoxide combination detector; and fire extinguisher: 2A:10:BC, fully charged.

At 2:35PM., LPAs inspected the backyard. Area was enclosed with tall fencing, with playthings in good repair. Home does not have any pools, fishponds, jacuzzi and bodies of water. (REFER TO 809C, FOR CONT)

Marie Rodriguez
Luis Gomez
	DATE: 11/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023

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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Document Has Been Signed on 11/13/2023 04:41 PM - It Cannot Be Edited

Created By: Luis Gomez On 11/13/2023 at 03:38 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: GONCALVES DE SOUZA, ELEANDRA	FACILITY NUMBER: 414004855
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102419(d)

Admission Procedures and Parental and Authorized Representative's Rights

(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	At 3:30PM., Based on record review, LPAs confirmed required 'Notification of Parent's Rights' and ‘Consent for Medication Treatment’ forms missing from the children's files. This poses a potential health and safety risk to children in care.
	POC Due Date: 11/20/2023
	Plan of Correction
1 2 3 4	Licensee will ensure missing forms are signed by authorized representative and stored in the children's record by the due date: 11/20/2023.

Type B

Section Cited

CCR

102425(e)

(e) No infant shall be forced to sleep, to stay awake, or to stay in the designated sleeping area. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	At 2:15PM., Based on observations, LPAs confirmed infant, S1, inside napping crib while awake. This poses a potential health and safety risk to children in care.
	POC Due Date: 11/20/2023
	Plan of Correction
1 2 3 4	Licensee will review safe sleep PIN 20-24, by the due date: 11/20/2023. 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: 11/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023

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: 11/13/2023

NARRATIVE

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(Page 2)
At 2:50PM., LPA reviewed facility records including the children’s files and staff files: Children’s files were reviewed and included the: Identification of Emergency Information (LIC702); Notice of A-type Deficiency (LIC9224); and Immunization Records.

At 3:30PM., Based on record review, LPAs confirmed required 'Notification of Parent's Rights' and ‘Consent for Medication Treatment’ forms missing from the children's files.

Licensee is reviewing and documenting napping conditions for every 15 minute review for infants in care.

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

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.

Licensee is conducting required emergency disaster drills, with last drill completed on: 10/2/2023, properly logged.

Required forms are posted in entry way, including the Childcare License; Notification of Parent’s Rights (PUB379); and Emergency Disaster Plan (LIC610A).

LPAs reminded licensee to update children's roster (LIC9040).

Per licensee, isolation of an ill children is in the playroom.

Per licensee, she provides food service for children in care. LPA advised licensee to ensure all children’s food containers brought by families are be labeled. Per licensee, home does not have any firearms.

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. (REFER TO 809C, FOR CONT.)

SUPERVISOR'S NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023

LIC809 (FAS) - (06/04)

Page: 5 of 6

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: 11/13/2023

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(Page 3)

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.

Licensee was informed of the www.mychildcareplan.org site is a consumer education website that helps families obtain child care by connecting to child care providers and resources and referral agencies (R&R) throughout California.

Incidental Medical Services (IMS) policy was discussed. For IMS information, see PIN 20-02-CCP. When an IMS is provided, a plan for 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- 0382 (TTY) and link to publications: Commonly asked questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

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 tool, please send them 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/inforesource/community-care-licensing/inspection-process.

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. Exit interview, appeal rights, plan of correction and report was conducted with licensee, Eleandra Goncalves de Souze. Licensee’s signature of this form acknowledges receipt of these documents.

During exit interview, licensee, Eleanadra Goncalves de Souza, confirmed that there are no registered sex offenders living in the facility, and LPA completed the RSO profile. Notice of site visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023

LIC809 (FAS) - (06/04)

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