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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414000210
Report Date: 01/24/2022
Date Signed: 01/24/2022 03:03:10 PM

Document Has Been Signed on 01/24/2022 03:03 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:JIMENEZ, LILIANAFACILITY NUMBER:
414000210
ADMINISTRATOR:JIMENEZ, LILIANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 544-6604
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY: 12TOTAL ENROLLED CHILDREN: 7CENSUS: 7DATE:
01/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:44 PM
MET WITH:Liliana JimenezTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Marie Rodriguez conducted an unannounced Annual inspection. LPA met with Licensee Liliana Jimenez and explained purpose of inspection. Home is a single story house with 3 bedrooms and 1 bathroom. Present in home were the Licensee, her husband, a helper, and 7 children (1 infant and 6 preschool age). Licensee is operating within capacity requirements on this day. All adults living or working in the home have a criminal record clearance on file. Hours of operation are Monday to Friday from 7:30am to 5:30pm.

Day Care Areas: Garage that is converted into a day care room, patio (front portion of the backyard), and bathroom. Bedroom #1, bedroom #2, and bedroom #3 are for napping infants only. Off Limit Areas: Kitchen, living room, back portion of the backyard, and front yard. LPA toured day care areas of home with Licensee. LPA observed home to be clean and in good repair with proper temperature and ventilation. Per Licensee, there are no weapons or firearms in the home. There is a variety of age appropriate toys and equipment in the home which are in good condition. The patio is fenced for supervision. Patio has outdoor age appropriate toys and equipment which are in good repair. Play structures have sufficient padding underneath. All cleaning supplies, poisons, and other chemicals are stored inaccessible to children. There is a working smoke detector and carbon monoxide detector, a fully charged fire extinguisher, and a working telephone. Phone number listed for Licensee is current.

Seven children's records reviewed were complete. All children have a record of emergency identification information on file. Licensee and helper record were reviewed and complete. Licensee and helper have current Pediatric First Aid/CPR certificate which expire January 2024. Last emergency drill was conducted on January 2022. Emergency drills are conducted monthly and are properly logged.

No deficiencies cited today under California Code of Regulations, Title 22, Division 12.

(Continued on next page)
SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Marie Rodriguez
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2022
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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: JIMENEZ, LILIANA
FACILITY NUMBER: 414000210
VISIT DATE: 01/24/2022
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Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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 (US DOJ) 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: http:://www.ada.gov/childqanda.htm.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email to [email protected]. 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/process.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

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-and-resources/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.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with Licensee Liliana Jimenez.
SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Marie Rodriguez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2022
LIC809 (FAS) - (06/04)
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