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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004916
Report Date: 08/28/2024
Date Signed: 08/28/2024 02:12:51 PM

Document Has Been Signed on 08/28/2024 02:12 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:CHAVEZ, MARISOLFACILITY NUMBER:
414004916
ADMINISTRATOR/
DIRECTOR:		CHAVEZ, MARISOLFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 544-0521
CITY:MENLO PARKSTATE: CAZIP CODE:
94025
CAPACITY: 14TOTAL ENROLLED CHILDREN: 4CENSUS: 4DATE:
08/28/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Marisol ChavezTIME VISIT/
INSPECTION COMPLETED:
02:25 PM
NARRATIVE
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On August 28, 2024, at approximately 9:20am Licensing Program Analysts (LPAs) Alvarado and Medrano conducted an unannounced Annual inspection and met with license Marisol Chavez. LPA Alvarado disclose the purpose of the of the inspection which was an annual inspection and entered the facility to begin the inspection. Present in the facility are Licensee and Licensees assistant supervising four Infants. During the inspection, the licensee is within capacity limits. All adults living and working in the facility are fingerprint cleared and associated.

Licensee rents home, which is a two-bedroom one bathroom house with front and backyard, and garage. Licensee lives in home with two other adults and two minor children. The hours of operation are Monday-Friday from 8am-5pm. LPAs inspected for health and safety hazards. Daycare areas are: Living Room, Dining Room, kitchen, Bathroom #1, and portion of the backyard. OFF limit areas are: Bedroom #2, front yard, driveway, and garage. All off limit areas are properly barricaded.

LPAs observed the Day-care is clean, orderly with a variety of age-appropriate toys for the children. All furniture inspected is in good repair. During tour of home cleaning supplies were found in areas that were on limits to children, but children were not present when found. Per licensee the home has no pools or bodies of water in the home, during inspection LPAs did not observe any bodies of water. The home has a fireplace in the living room that is properly barricaded. The home has age-appropriate equipment available for children in care. Licensee was reminded that baby walkers, bouncers, jumpers and any other similar items are to not be used for children in care. LPAs observed pack and play to be free of loose of objects and/or articles.

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SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Diana Alvarado
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2024
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 08/28/2024 02:12 PM - It Cannot Be Edited


Created By: Diana Alvarado On 08/28/2024 at 12:18 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: CHAVEZ, MARISOL
FACILITY NUMBER: 414004916

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(4)
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: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above out of, which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2024
Plan of Correction
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During visit licensee removed cleaning supplies and Licensee will submitt evidence such as phtos of safety locks installed for an area that contains cleaning supplies.
Type B
Section Cited
CCR
102425(j)(2)(D)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 4 out of children sleep logs were not made available for review. which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2024
Plan of Correction
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Licensee will submitt proof of sleep logs that are being documented of infants.
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:Diana Alvarado
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024


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Document Has Been Signed on 08/28/2024 02:12 PM - It Cannot Be Edited


Created By: Diana Alvarado On 08/28/2024 at 12:19 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: CHAVEZ, MARISOL
FACILITY NUMBER: 414004916

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)1
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: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.

Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above out of, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2024
Plan of Correction
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Licesnsee will submiit proof of Emergency drills that need to be conducted 1 every 6 months.

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:Diana Alvarado
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024


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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: CHAVEZ, MARISOL
FACILITY NUMBER: 414004916
VISIT DATE: 08/28/2024
NARRATIVE
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There was a fully charged fire extinguisher, A smoke alarm and carbon monoxide alarm, and a working telephone which is the Licensees cell phone. Phone number listed for Licensee is current. Per Licensee, there are no weapons or firearms in the home. LPAs reviewed four children’s records which were missing documentation of the LIC 9227, no infants currently that are under 12 months as well as sleeping logs for infants. Licensee stated that she is always in the room with the children when they are sleeping and had conducted but could not find logs during inspection. Licensees’ Pediatric CPR/First Aid certification Expires 1/2026. Based on review of files it was found that the mandated reporter training for the licensee and assistant were expired, licensee’s training expired on 7/2024.

All the required posting documentation, such as the facility license, Notification of Parental Rights and have been placed in a prominent area for parents or representatives to review. Licensee is missing a few and was reminded of the missing forms. According to licensee emergency drills are conducted at least once every six months, Licensee was not able to provide documentation of the last emergency drill.

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.

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.

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SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Diana Alvarado
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
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: CHAVEZ, MARISOL
FACILITY NUMBER: 414004916
VISIT DATE: 08/28/2024
NARRATIVE
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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.

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/.

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.

During the exit interview, Licensee, Marisol, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS. A notice of site visit was given and must remain posted for 30 days.

California code of Regulations, Title 22 deficiencies are being cited in the following page(s):
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Diana Alvarado
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
LIC809 (FAS) - (06/04)
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