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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 10:52:47 AM

Document Has Been Signed on 12/05/2022 10:52 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: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:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensee, Andrea JimenezTIME COMPLETED:
11:00 AM
NARRATIVE
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On December 5th, 2022, Licensing Program Analyst (LPA) Tapia-Mandujano conducted a Case Management along with a complaint investigation visit. The purpose of this inspection is to cite facility for not following Safe Sleep regulations. Present in the facility are licensee and a staff caring for 4 children (3 infants and 1 preschool age). LPA and licensee inspected the facility for health and safety hazards.

On a complaint investigation that was received by the department on 10/05/22, during the course of the investigation licensee received pertinent information that documented a child who was sleeping in a stroller with a blanket during outside play.

Based on that observation, deficiencies were observed in the areas evaluated according the Title 22 Division 12 Ca. Code of Regulations. Please refer to LIC 809D for more details. Safe Sleep regulations have been discussed with licensee.

After today’s visit, an exit interview was conducted with Licensee, Andrea Jimenez. A copy of this report was reviewed and provided to Director.
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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Document Has Been Signed on 12/05/2022 10:52 AM - It Cannot Be Edited


Created By: Leslit Tapia-Mandujano On 12/05/2022 at 09:54 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: JIMENEZ, ANDREA
FACILITY NUMBER: 414004859

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/05/2022
Section Cited
CCR
102425(i)

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102425(i): Infant Safe Sleep: If an infant falls asleep before being placed in a crib or play yard, the provider shall move the infant to a crib or play yard as soon as possible.

This requirement is not met by:
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Licensee agrees moving forward to put all sleeping infants in a safe place to sleep when infants fall asleep anywhere that is not a crib or play yard.
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Based on observation, the licensee did not comply with the section cited above as there was documentation that a child was sleeping in a stroller during outside play, which poses a potential health, safety or personal rights risk to persons in care.
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LPA reviewed the dafe sleep regulations to licensee and provided a copy for personal record.

An informal meeting may be scheduled to dicuss the deficiencies.

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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:Cindy Interiano
LICENSING EVALUATOR NAME:Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2022


LIC809 (FAS) - (06/04)
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