414004876-11-29-2023-05-CC-LGOZ-CY33UM-20231129173346

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414004876
Report Date: 11/29/2023
Date Signed: 11/29/2023 05:34:28 PM

Document Has Been Signed on 11/29/2023 05:34 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:	LOPEZ GUZMAN, DAISY N.		FACILITY NUMBER:	414004876
ADMINISTRATOR:	LOPEZ GUZMAN, DAISY N.		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(650) 520-1249
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94402
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 6	DATE:	11/29/2023
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME BEGAN:	02:50 PM
MET WITH:	Daisy Lopez Guzman		TIME COMPLETED:	05:40 PM

NARRATIVE

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On 11/29/2023 at 2:50PM., Licensing Program Analysts (LPA), Luis J. Gomez met with Licensee, Daisy Lopez Guzman. Purpose of the inspection was explained and was for an Unannounced; Annual Random. Present was the licensee and helper, caring for 6 children (3 Infant-age, 3 School- age). Adults have criminal record clearances on file. Licensee’s home is a 3 bedroom, 2 bathroom, 1 level townhouse. Days and hours of operations are: Monday- Friday, 8:00 AM., to 5:30 PM. Day-care Areas are: Living Room (Playroom), Bedroom #1 (Napping only), Dining Room, Bathroom #1 and the Outdoor Play Area (Patio). Off-limit Area are: Bedroom #2, Bedroom #3, Bathroom #2, Garage Area, #1 (Pass through only), Garage Area #2 (Pass through only), Garage Area #3/ Studio unit, Kitchen (Pass through only) and Laundry Area. LPA inspected home, inside and outside with licensee for health and safety hazards.

At 2:55PM., the following was observed: Facility was clean, orderly, with age-appropriate playthings available for the children. Floors and ground surfaces was clear of obstructions or potential hazards. Furniture, toys, and books inspected were in good repair. Licensee observed storage cubbies for children’s belongings. Playroom has child sized tables and chairs for seated activities. For napping services, LPA observed several napping mats, and cribs with tight-fitting sheets. Crib/ plan pen was available for each infant in care.

At 3:00PM., Based on observations, interview and record review, LPA confirmed an off-limit area (Bedroom #2), is being used for napping services.

Bathroom #1 was maintained 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 3:35PM., LPA inspected the outdoor play area. Area was enclosed with tall fencing, with playthings in good repair. Home does not have any pools, fishponds, jacuzzi and bodies of water.

At 3:39PM., Based on observations, LPA confirmed accessible paint can, located in the outdoor play area. Paint can was removed during inspection.

(REFER TO 809C, FOR CONT)

SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

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 11/29/2023 05:34 PM - It Cannot Be Edited

Created By: Luis Gomez On 11/29/2023 at 04:37 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: LOPEZ GUZMAN, DAISY N.	FACILITY NUMBER: 414004876
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)

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: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	At 3:39PM., Based on observations, LPA confirmed accessible paint can, located in the outdoor play area. This poses a potential health and safety risk to children in care.
	POC Due Date: 11/30/2023
	Plan of Correction
1 2 3 4	Licensee removed accessible paint can from on-limit area during inspection. Deficiency has been cleared.

Type B

Section Cited

CCR

102416.3(a)(6)

(a) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following: (6) Any change from an area of the family child care home previously identified as "off limits" to an area where care and supervision will be provided to children in care. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	At 3:00PM., Based on observations, interview and record review, LPA confirmed off-limit area (Bedroom #2) being used for napping services. This poses a potential health and safety risk to children in care.
	POC Due Date: 12/04/2023
	Plan of Correction
1 2 3 4	Licensee will submit updated facility sketch (LIC999) to the department showing the new on/ off limit areas. Proof of correction will be submitted by the due date: 12/4/2023.

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: 11/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

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: LOPEZ GUZMAN, DAISY N.	FACILITY NUMBER: 414004876
	VISIT DATE: 11/29/2023

NARRATIVE

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(Page 2)
At 3:50PM., LPA reviewed facility records including the children’s files and staff files. Staff files were reviewed and included the: Proof of required immunization; Notification of Employee Rights (LIC9052); and Statement Acknowledging Requirement to Report Suspected Child Abuse (LIC9108).

Children’s files were reviewed and included the: Identification of Emergency Information (LIC702); Notification of Parent’s Rights; Affidavit Regarding Liability Insurance; Infant Sleeping Plan (LIC9227); and Immunization Records.

At 4:30PM., Based on record review and interview conducted, LPA confirmed day-care child’s file, C1, missing from facility records. Advisory Note: Technical Violation (LIC9102TV) was issued.

The license is documenting infant napping conditions during each 15 minute review.

Licensee’s Cardiopulmonary Resuscitation / First Aid certification is current, expiring on: 2/2024.

Licensee’s Mandated Reporter Training Certification (AB1207) is current, expiring on: 9/8/2025.

Per licensee, last disaster drill was conducted on 9/1/2023. LPA reminded licensee to document disaster drill conducted.

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

Licensee has update the 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.)

SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

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: LOPEZ GUZMAN, DAISY N.	FACILITY NUMBER: 414004876
	VISIT DATE: 11/29/2023

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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, Daisy Lopez Guzman. Licensee’s signature of this form acknowledges receipt of these documents.

During exit interview, licensee, Daisy Lopez Guzman 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.

SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023

LIC809 (FAS) - (06/04)

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