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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414002885
Report Date: 11/22/2021
Date Signed: 11/22/2021 11:25:34 AM

Document Has Been Signed on 11/22/2021 11:25 AM - 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:SANTIAGO, ANA BERTHAFACILITY NUMBER:
414002885
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 5DATE:
11/22/2021
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensee, Ana Berta SantiagoTIME COMPLETED:
11:35 AM
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On 11/22/2021 at 9:00A.M., Licensing Program Analyst (LPA), Luis J. Gomez met with Licensee, Ana Berta Santiago. The purpose of the inspection was explained and was for Case Management, Increase in Capacity inspection and to add Bedroom #1 and Bathroom #1 to the day-care areas. Present was the licensee and helper caring for five children (3- Preschool Age and 2- Infant Age) All adults in the home have their criminal record clearances on file. Day-care Areas are: Bedroom #2 (Back), Bathroom #2 (Back), Living Room (Playroom), Dining Room and Outdoor Play Area. Off-limit Areas are: Bedroom #1 (Front), Bedroom #1 (Front), Bedroom #3 and Front Patio. LPA inspected home indoors and outdoors with licensee for health and safety hazards.

At 9:05A.M., LPA observed the following: Day-care area was clean, orderly and had age appropriate toys, book and puzzles. All furniture and playthings inspected were in good repair. LPA observed child size tables and chairs available for snack and activities. Licensee had child safety gate to prevent access to off-limit areas. Bathroom #1 was maintained clean and all fixtures in proper working order. Licensee has several infant cribs stored in bedroom #2. Detergents and cleaning supplies are stored in off-limit area. All outlets and trash bins have been properly covered. Home has functioning telephone, smoke detector and fully charged fire extinguisher (3A:40:BC) located in the hallway. At 10:10A.M., LPA observed licensee does not have functioning carbon monoxide detector. LPA issued Advisor Note: Technical Assistance (LIC9102) during inspection.

At 9:15A.M., LPA inspected bedroom #1 and bathroom #1. Per licensee bedroom #1 will be used for napping only. Bathroom #1 and bedroom #1 were free of hazards or dangerous conditions. Areas were added during inspection. (Continuation on 809-C).

SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: SANTIAGO, ANA BERTHA
FACILITY NUMBER: 414002885
VISIT DATE: 11/22/2021
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(Page 2)

At 9:20A.M., LPA observed facility outdoor play area in completely enclosed. Toys and outdoor playthings that were in good repair. LPA observed area has adequate shading and soft turf had been installed. Utility shed, located in the outdoor play area, is made inaccessible to children. Home does not have a swimming pool, spa, hot tub, fishpond or other bodies of water.

Applicant was informed that the Department must be notified prior to the use of any off-limits area. Applicant’s CPR/ first aid certification is current and expires on: 6/11/2023. LPA reminded licensee to updated mandated reporter training certification.

Applicant was informed that all adults, 18 years and older who live in the home or assist with children, must have their criminal record clearance and association prior to having contact with day-care children. For background clearance transfers, applicant can submit the LIC 9182 with copy of CA DL or CA ID. Failure to comply could result in an immediate civil penalty of $100.00 per day. Applicant was reminded that as of September 1, 2016, a person may not be employed or volunteer at a childcare facility, unless he or she has been immunized for influenza, pertussis and measles or qualifies for an exemption pursuant to Health and Safety Code 1596.7995 and 1597.662.

Incidental Medical Services (IMS) 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 Americans with Disabilities Act (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: www.ada.gov/childqanda.htm.


Mandated Reporter Training is available on the CCLD website. Training must be completed every two years by the applicant and all facility staff. Training can be taken online: www.mandaterreporterca.com. (REFER TO PAGE 3 FOR CONT.)
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: SANTIAGO, ANA BERTHA
FACILITY NUMBER: 414002885
VISIT DATE: 11/22/2021
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(PAGE 3)

Applicant was informed about the Provider Information Notices located on the CCLD website. Safe Sleep handout was discussed. Applicant understands Individual Safe Sleep Plans (LIC9227) shall be completed for infants up to 12 months of age and maintained in the infant’s file.

Licensee was reminded that when operating at a large capacity, there must be a helper present. Large capacity limits were discussed with the licensee during inspection.

During inspection licensee submitted: COVID-19 self-assessment, LIC279, LIC279B LIC9108 and Proof of Immunization.

Prior to approval of large capacity, licensee must complete the following:

-Submit updated facility sketch showing on/off limit areas (LIC999)

-Submit Fire Clearance Approval Request (STD 850)

-Submit Preventive Health and Safety Practices Certification

-Submit Current Mandated Reporter Training Certificate

-Install Functioning Carbon Monoxide Alarm

-Install safety lock on accessible dryer

Based on inspection, no deficiencies were cited in the areas evaluated according the Title 22 Division 12 Ca. Code of Regulations. Exit interview conducted and report reviewed with Licensee, Ana Berta Santiago and her signature of this form acknowledges receipt of these documents.



This report must be available in the facility for public review. Notice of site visit was observed being posted. Licensee was advised any additional questions to call Office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website: www.cdss.ca.gov
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
LIC809 (FAS) - (06/04)
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