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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414002143
Report Date: 11/21/2024
Date Signed: 11/21/2024 05:01:15 PM

Document Has Been Signed on 11/21/2024 05:01 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:JIMENEZ, BIRGINIAFACILITY NUMBER:
414002143
ADMINISTRATOR/
DIRECTOR:		JIMENEZ, BIRGINIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 473-9598
CITY:EAST PALO ALTOSTATE: CAZIP CODE:
94303
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 5DATE:
11/21/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:45 PM
MET WITH:Licensee, Birginia JimenezTIME VISIT/
INSPECTION COMPLETED:
05:20 PM
NARRATIVE
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On November 21st, 2024 at approximately 8:45am, Licensing Program Analysts (LPAs) Tapia-Mandujano and Naves conducted an unannounced annual/random inspection. LPAs met with Licensee, Birginia Jimenez and explained the purpose of the inspection. Present in the facility are licensee caring and supervising 5 children (2 infants, 1 preschooler, and 2 school-age children). All adults present today have fingerprint clearance and are associated.

Licensee owns the home and lives with adult husband, adult son, and minor children. Home is a one story house with four bedrooms, three bathroom, and an enclose front and back yard. The hours of Operation are Monday-Friday from 7am-5:30pm. Day Care Areas: Living room, Dining area, Bathroom #1, and portions of the front yard. Off limit areas are: Kitchen, Bedrooms #1-4, Bathrooms #2-3, Backyard, Side yards, and portions of the Front yard. All off limit areas, including closets, are maintained properly barricaded.



LPAs observed home to be clean and in good repair with proper temperature and ventilation. There were a variety of age appropriate toys and equipment in the home which were in good condition. Home does have a fireplace that is properly barricaded. Per licensee, there are no pets in the home. There were no pools, spas or bodies of water on the property. LPAs advised licensee about water safety hazards. All cleaning supplies, poisons, and other chemicals were stored inaccessible to children. Discipline Policy was discussed. Isolation Area a sick child will be in the living room.

There was a fully charged fire extinguisher, smoke alarm and carbon monoxide alarm, and a working telephone on site. Phone number listed for Licensee is updated in the system. Per Licensee, there are weapons, and/or firearms in the home. LPAs observed the weapons and/or firearms are kept in a safe in an off limit area. Infant children are sleeping in pack and plays in the living room. Sleep logs were not being logged. LPAs advised Sleep logs are for all infant children up until 24 months (Technical Violation was Issued).

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SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
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 11/21/2024 05:01 PM - It Cannot Be Edited


Created By: Leslit Tapia-Mandujano On 11/21/2024 at 04:21 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: JIMENEZ, BIRGINIA
FACILITY NUMBER: 414002143

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(b)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as there were blankets in a pack and play where children were sleeping which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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LPAs explained safe sleep regulations to licensee and provided PIN 20-24-CCP.

Licensee understands that no blankets shall be in pack and play and will not have any blankets and/or objects in them when children are sleeping.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2024


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: JIMENEZ, BIRGINIA
FACILITY NUMBER: 414002143
VISIT DATE: 11/21/2024
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LPAs reviewed 5 children's file and facility files. Children's files were complete. Facility files were completed. Licensees CPR & First Aid Certificate expires on 01/2026. Licensee's Mandated Reporter Certificate has expired 12/2024. Last emergency drill was conducted 11/2024. LPAs reminded that Emergency Drills must be conducted at least once every six months and be properly logged. All the required posting documentation, such as the facility license, Notification of Parental Rights have been placed in a prominent area for parents or representatives to review.

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 atwww.cdss.ca.gov/inforesources/community-care-licensing/inspection-process

Licensee was reminded that all adults 18 and over, 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 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.

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.



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SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
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: JIMENEZ, BIRGINIA
FACILITY NUMBER: 414002143
VISIT DATE: 11/21/2024
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Incidental Medical Services (IMS) policy was discussed. Licensee does not offer IMS at this time. 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, the licensee, Birginia Jimenez, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS on 11/21/24.

***Deficiencies were cited today under California Code of Regulations, (Title 22, Div. 12, Ch 3)



A Notice of Site Visit was given and must be posted for 30 days.

Exit interview conducted and report was reviewed with the licensee, Birginia Jimenez.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
LIC809 (FAS) - (06/04)
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