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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214005610
Report Date: 04/13/2022
Date Signed: 04/13/2022 04:52:18 PM

Document Has Been Signed on 04/13/2022 04:52 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:SOUZA, KARINAFACILITY NUMBER:
214005610
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
04/13/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Karina SouzaTIME COMPLETED:
11:10 AM
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Licensing Program Analysts (LPA) Haydee Caliboso met with Karina Souza for a pre-licensing inspection of the home on 4/13/22. The applicant rents the home, located on the lower level with 2 bedrooms and 1 bathroom. The applicant lives with the husband, 2 daughters; 1 school age and 1 adult. The applicant and the adults living in the home have been fingerprinted and all cleared. The hours of operation are Monday - Friday, 8:00AM to 5:00PM. The facility will provide care for children between birth to 5 years old. During the inspection, capacity and ratio requirements were discussed and reviewed with the applicant. There is proper lighting and ventilation in the home, a working telephone, fully functioning smoke and carbon monoxide detectors, and a fully charged 2A10BC fire extinguisher. Applicant’s home is clean, orderly, and equipped with age-appropriate materials and books available for children. LPA observed there are no baby walkers, bouncers, or exersaucers in the home.

Childcare will be provided in the following areas: living room, bedrooms #1 & #2, hallway bathroom, and backyard patio. LPA reminded the licensee that active supervision must be observed at all times when children are present. Bedrooms #1 & #2 will be used for napping children. The hallway will be used as isolation area for ill children. First Aid kit supplies are available and stored in a locked cabinet. The backyard patio of the home is gated and fenced off.

Off limit areas: Kitchen area. All cleaning supplies, detergents, and toxins are stored in a locked cabinet made inaccessible to children. Kitchen knives and sharp tools are stored where they are made inaccessible to children. Applicant will provide meals and snacks for the children.
Cont. 809-C pg. 2
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Haydee R Caliboso
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2022
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: SOUZA, KARINA
FACILITY NUMBER: 214005610
VISIT DATE: 04/13/2022
NARRATIVE
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There is no body of water such as a swimming pool, spa, hot tub, or fishpond in the home. The home has no fireplace. There are no weapons or firearms in the home. All areas that are off-limits are made inaccessible to children. LPA’s observed that all cabinets and doors have locks and safety latches.

The applicant was reminded there are no walkers, exersaucers, jumpers, bouncers or any similar items to be used for children in care and shall be made inaccessible. LPA informed the applicant that emergency drills will be conducted at least once every six months and drills must be properly logged. The applicant's First Aid/CPR certificate expires in 4/2023. LPA discussed facility ratios and capacities with the applicant. LPA discussed Mandated Reporter training available on the CCLD website. In addition to the AB1207 training must be completed every two years by all staff hired, a one-time General Training is also required. Training can be taken online at www.mandaterreporterca.com. The LPA reviewed and discussed all necessary requirements to administer medical treatment. LPA reviewed and discussed isolation of sick children. Positive redirection will be used for discipline.

Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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 applicant 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 applicant 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.
Cont. 809-C pg. 3
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Haydee R Caliboso
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022
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: SOUZA, KARINA
FACILITY NUMBER: 214005610
VISIT DATE: 04/13/2022
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This facility plans to provide Incidental Medical Services – IMS. For IMS information , see PIN 22-02-CCP. 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: http://www.ada.gov/childqanda.htm

LPA reviewed with applicant the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. Entrance Checklist was provided to the applicant.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.
To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

On 4/13/22 LPA Haydee Caliboso received LIC 9217. LPA emailed and received FCC self-certification to the applicant on 4/13/22. A copy will be kept in the applicant’s file.

Exit interview conducted and report was reviewed with the applicant, Karina Souza.
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Haydee R Caliboso
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022
LIC809 (FAS) - (06/04)
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