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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004982
Report Date: 08/03/2023
Date Signed: 08/03/2023 03:03:35 PM

Document Has Been Signed on 08/03/2023 03:03 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:VAZQUEZ, MARIA ISABELFACILITY NUMBER:
414004982
ADMINISTRATOR:VAZQUEZ, MARIA ISABELFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 284-9261
CITY:EAST PALO ALTOSTATE: CAZIP CODE:
94303
CAPACITY: 14TOTAL ENROLLED CHILDREN: 9CENSUS: 4DATE:
08/03/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Licensee, Maria Isabel VazquezTIME COMPLETED:
03:30 PM
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On August 3rd, 2023 at approximately 1:10pm, Licensing Program Analyst, (LPA) Tapia-Mandujano arrived at the facility to conduct an inspection and met with Licensee, Maria Isabel Vazquez. Facility is operating within capacity limits. All adults present in the facility are fingerprint cleared and associated.

During the course of the investigation of a complaint, it was determined and confirmed by licensee on 5/16/23 that there was an unfingerprinted adult living and working in the child care facility. Due to this determination, there was an immediate health and safety risk for the children in care. Please see LIC 809D for more details.

Type “A” violations were issued today. Licensee is advised to provide a copy of the Evaluation Report and all Type “A” Deficiencies cited, to the parents and guardians of children currently enrolled in care and to parents of newly enrolled children during the next 12 months. A signed and dated LIC 9224 shall be maintained in all Children's files. Notice of site Visit will be posted and should remain posted for 30 days, failure to post will result in an immediate civil penalty.

This report must be available in the facility for public review. Notice of site visit shall be posted for 30 days from today's visit. An exit interview was conducted with licensee, Maria Isabel Vazquez.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2023
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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Document Has Been Signed on 08/03/2023 03:03 PM - It Cannot Be Edited


Created By: Leslit Tapia-Mandujano On 08/03/2023 at 02:17 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: VAZQUEZ, MARIA ISABEL
FACILITY NUMBER: 414004982

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/04/2023
Section Cited
CCR
102370(d)

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102370(d): Criminal Record Clearance: All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
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Licensee will ensure that all adults living and working in the facility will have fingerpint clearance and are associated prior to be present in the facility.
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Based on interview and record review, the licensee did not comply with the section cited above as there was an unfigerprinted adult living and working in the home, which poses an immediate health, safety or personal rights risk to persons in care.
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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: 08/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2023


LIC809 (FAS) - (06/04)
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