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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004901
Report Date: 09/08/2022
Date Signed: 09/08/2022 01:02:34 PM

Document Has Been Signed on 09/08/2022 01:02 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:TEJADA, GRACIELA Y. & TEJADA, MIGUEL A.FACILITY NUMBER:
414004901
ADMINISTRATOR:TEJADA, GRACIELA & MIGUELFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 401-3821
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 14TOTAL ENROLLED CHILDREN: 10CENSUS: 9DATE:
09/08/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Graciela TejadaTIME COMPLETED:
01:05 PM
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On September 8, 2022 at approximately 11:45am, Licensing Program Analyst (LPA) Catrina Quimbo conducted an unannounced, case management inspection, in regards to an unusual incident that occurred in the home 08/23/2022. LPA met with licensee, Graciela Tejada, and explained the purpose of the inspection. Present in the home included both licensees, licensees' assistant and 9 enrolled children (3 infants and 6 preschool age). Facility is operating within capacity limits and ratio during LPA's visit. All adults living and/or working in the home have a criminal record clearance on file.

Licensee self reported to department of unusual incident 08/25/2022. On 08/23/2022 at approximately 12:55pm, 17 month old, enrolled child (C1) was placed in a crib for nap time, located in the home's living room. Licensee stated all enrolled children and both licensees were also in living room. Per licensee, while holding another enrolled child, C1 attempted to climb out of crib and fell on both their hands.

C1 was provided aid by licensee with an ice pack. Licensee did not observe C1 to have any bruises or marks, however, contacted C1's authorized representative of incident. C1 was brought to doctor's office by authorized representative. On 08/24/2022, licensee was informed C1 sustained a fracture in left arm.

During LPA's visit, LPA observed living room to be an open space equipped with a crib and cots for napping. Additional cribs are located in bedroom #1 for younger infants. Per licensee, C1, older infants and preschool age children nap in living room.

C1 returned to licensees' home 08/26/2022 with arm sling. Since incident, C1 utilizes a cot for napping purposes.

LPA did not observe cribs to have any loose articles located in, hanging above or around crib. LPA reminded licensees any child over 12 months that is able to stand, walk, or climb, should sleep in cot or mat instead of crib. LPA advised licensee to discuss safe sleep regulations with children's authorized representatives.
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SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2022
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: TEJADA, GRACIELA Y. & TEJADA, MIGUEL A.
FACILITY NUMBER: 414004901
VISIT DATE: 09/08/2022
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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-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.

After today's visit, no deficiencies were cited.

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 the licensee, Graciela Tejada.
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022
LIC809 (FAS) - (06/04)
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