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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004859
Report Date: 12/05/2022
Date Signed: 12/05/2022 12:48:02 PM

Document Has Been Signed on 12/05/2022 12:48 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:JIMENEZ, ANDREAFACILITY NUMBER:
414004859
ADMINISTRATOR:JIMENEZ, ANDREAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 454-7249
CITY:EAST PALO ALTOSTATE: CAZIP CODE:
94303
CAPACITY: 14TOTAL ENROLLED CHILDREN: 8CENSUS: 4DATE:
12/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Licensee, Andrea JimenezTIME COMPLETED:
01:00 PM
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On December 5th, 2022 at approximately 11am, Licensing Program Analyst (LPA) Tapia-Mandujano conducted an unannounced required annual inspection. Purpose of the inspection was explained. LPA met with licensee, Andrea Jimenez. Present in the facility are licensee and assistant caring for 4 children (3 infants, 1 preschooler). Facility is currently operating within capacity limits. All adults living and working in the home have fingerprint clearance and associated to the facility.

Licensee rents home and lives with adult brother. Home is a one story house with three bedrooms, one bathroom, and an enclose front and back yard. The hours of Operation are Monday-Friday from 8am-5pm. DAY CARE AREA: Living Room, dining room (eating only), Bedroom #2 (sleeping only), Bathroom #1, and backyard OFF LIMITS AREA: Bedroom #1, Bedroom #3, Kitchen, Garage, and front yard. All off limit areas, including closets, are maintained properly barricaded.

LPA toured day care areas of home with Licensee to inspect for health and safety hazards. LPA 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 not have a fireplace. There are no pets in the home. There are no pools, and bodies of water in the premises. All cleaning supplies, poisons and other chemicals were stored inaccessible to children. Discipline Policy was discussed.

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 current. Per Licensee, there is a firearm in the home. Firearm is kept in a off limit area seperate from where children are supervised. LPA was unable to see the firmarm due to the room/safe being locked. LPA requested a photo of how firearms is being stored. observed that the weapons are kept in an off limit areas separate where children are supervised.

LPA reviewed four children's' record. LPA also reviewed facility and assistant records. Licensees CPR & First Aid Certificate will expire 11/2023. Licensee's Mandated Reporter Training expires 11/2023. Last Emergency drill was conducted 07/2022. Emergency drills must be conducted at least once every six months and should be properly logged.

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SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2022
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: JIMENEZ, ANDREA
FACILITY NUMBER: 414004859
VISIT DATE: 12/05/2022
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Incidental Medical Services (IMS) policy was discussed. Licensee does not offer IMS. 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 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.

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.

Licensee was reminded that all adults 18 and over living or working in the home, 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 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.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee, Andrea Jimenez.
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022
LIC809 (FAS) - (06/04)
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