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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004024
Report Date: 07/06/2023
Date Signed: 07/06/2023 12:11:00 PM

Document Has Been Signed on 07/06/2023 12:11 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 CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:AQUINO, ANNABELLEFACILITY NUMBER:
414004024
ADMINISTRATOR:AQUINO, ANNABELLEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 734-6514
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 4DATE:
07/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Annabelle AquinoTIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Andrea Medlin met with facility representative for this required annual licensing visit today. Purpose of visit explained. Days and hours of operation: Monday-Friday 7:00AM-6:00PM. There are 4 children in care today; 3 infants and 1 preschool. Licensee states she, mother, father, adult son, and adult daughter live in the home; criminal record clearance is on file for all adults in the home. Physical plant toured to inspect for health and safety hazards in the licensed areas. Outdoor space inspected for health and safety hazards; outdoor areas are to remain off limits as of today as there is debris and licensee states neighbor is doing construction which is causing dust to come into her yard. The daycare has a fully charged fire extinguisher that meets the minimum requirements, smoke detectors, and a carbon monoxide (CO) detector in the home. First aid supplies are available. Detergents, cleaning compounds, medications, and other items which could pose a danger to children is stored inaccessible to children. Per Licensee, there are no firearms or weapons in the home. No spas, swimming pools, hot tubs, fish ponds, or similar bodies of water are present. Variety of age appropriate toys and materials is observed in the daycare. A sick child would be separated from the group and wait for parent to pick up. Licensee has expired Pediatric First Aid and CPR certification (exp 5/2023) however can show proof she is registered for a course on 7/28/2023. Staff and children's files reviewed. In the files reviewed, some are incomplete. Licensee has the required staff immunizations: measels (MMR) and pertussis (Tdap). Licensee has the mandated child abuse reporter training as compliant with AB1207 (exp 3/26/2024). All the required forms are posted: license, parent's rights, emergency disaster plan.

(Continued on next pages 809-C and 809-D)
SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Andrea Medlin
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: AQUINO, ANNABELLE
FACILITY NUMBER: 414004024
VISIT DATE: 07/06/2023
NARRATIVE
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LPA 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. Incidental Medical Services (IMS) policy discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA is 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. Facility informed that effective September 1, 2016, a person may not be employed or volunteer at a child care facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

The deficiencies cited on the following pages are in violation of the California Code of Regulations, Title 22, Division 12, Chapter 1. This report is reviewed with facility representative and a copy of this report must be made available for public review upon request.


Notice of Site Visit posted and shall remain posted for 30 days.

SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Andrea Medlin
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023
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Document Has Been Signed on 07/06/2023 12:11 PM - It Cannot Be Edited


Created By: Andrea Medlin On 07/06/2023 at 10:01 AM
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: AQUINO, ANNABELLE
FACILITY NUMBER: 414004024

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
Section Cited
Deficient Practice Statement
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4
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:Daniel J Oquendo
LICENSING EVALUATOR NAME:Andrea Medlin
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2023


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Document Has Been Signed on 07/06/2023 12:11 PM - It Cannot Be Edited


Created By: Andrea Medlin On 07/06/2023 at 10:30 AM
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: AQUINO, ANNABELLE
FACILITY NUMBER: 414004024

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417


This requirement is not met as evidenced by: Children's files are incomplete. See LIC 857 - Children's Record Review for a list of what is missing in each child's file.
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in three out of four which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/27/2023
Plan of Correction
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By 7/27/2023, all children's files shall be complete. A return unannounced visit will be conducted to verify correction.
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:Daniel J Oquendo
LICENSING EVALUATOR NAME:Andrea Medlin
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2023


LIC809 (FAS) - (06/04)
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