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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004409
Report Date: 08/16/2023
Date Signed: 08/16/2023 04:02:57 PM

Document Has Been Signed on 08/16/2023 04:02 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:HERNANDEZ, DEBORAFACILITY NUMBER:
414004409
ADMINISTRATOR:HERNANDEZ, DEBORAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 535-9811
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 11DATE:
08/16/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Debora HernandezTIME COMPLETED:
04:10 PM
NARRATIVE
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On 8/16/2023 at 2:05PM., Licensing Program Analyst (LPA), Luis J. Gomez met with licensee, Debora Hernandez. Purpose of inspection was explained and is for an unannounced, plan of correction inspection. Present is licensee, licensee's daughter, assistant caring for 11 children. (5 infant age, 5 preschool age, 1 school age). Staff present have criminal record clearances on file. LPA inspected the facility with licensee for health and safety hazards.

During inspection, LPA performed facility record review, observations and interviews.

At 2:15PM., Based on observations, interview and record review, LPA confirmed facility operating beyond the capacity limit stated on the license, with 5 infant- age children in care.

At 3:00PM., Based on interview and record review, LPA confirmed licensee is not documenting infant napping conditions for every 15 minutes review.

At 3:10PM., Based on observations, LPA confirmed loose articles inside an infant play pen in napping room (bedroom #1).



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, evaluation report, and plans for correction was discussed Debora Hernandez and licensees' signature of this form acknowledges receipt of these documents.

Civil Penalty of $1,300.00 was issued during inspection.

Type “A” violations were 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.

Notice of site visit was provided during inspection.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2023
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 08/16/2023 04:02 PM - It Cannot Be Edited


Created By: Luis Gomez On 08/16/2023 at 01:48 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: HERNANDEZ, DEBORA
FACILITY NUMBER: 414004409

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/17/2023
Section Cited
CCR
102416.5(a)

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102416(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 will reduced infant enrollment to required capacity limit of 4, by the due date: 8/17/2023.

Licensee will submit updated children's roster to the department. Licensee will provide names, contact information of children and family no longer receiving childcare services.
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At 2:15PM.,Based on observations, interview and record review, LPA confirmed facility operating beyond the capacity limit stated on the license, with 5 infant- age children in care. This poses an immediate health and safety risk to children in care.
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Civil Penalty of $1,300.00 was issued during inspection.

Conference will be scheduled at the San Bruno Childcare Regional Office at a later date.

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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: 08/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/16/2023 04:02 PM - It Cannot Be Edited


Created By: Luis Gomez On 08/16/2023 at 02:57 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: HERNANDEZ, DEBORA
FACILITY NUMBER: 414004409

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/18/2023
Section Cited
CCR
102425(j)(2)(D)

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102425(j)(2)(D) Infant Safe Sleep. Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: a. date b. Infant’s name c. time of each 15-minute check. This requirement was not met as evidenced by:
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Licensee will begin documenting each 15 minute review for napping infants in care by due date: 8/18/2023.
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At 3:00PM., Based on interview and record review, LPA confirmed licensee is not documenting infant napping conditions for every 15 minutes review. 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.
Type B
08/18/2023
Section Cited
CCR102425(b)

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102425(b) Infant Safe Sleep. (b) Cribs or play yards shall be free from all loose articles and objects. This requirement was not met as evidenced by:
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Licensee will remove all loose articles from infant crib. Licensee will draft plan to always maintain empty napping crib for infants in care by due date: 8/18/2023.
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At 3:10PM., , Based on observations, LPA confirmed loose articles inside an infant play pen in napping room (bedroom #1). 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: 08/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023


LIC809 (FAS) - (06/04)
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