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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434402998
Report Date: 05/05/2022
Date Signed: 05/06/2022 08:29:19 AM

Document Has Been Signed on 05/06/2022 08:29 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:MURILLO, GRABIELAFACILITY NUMBER:
434402998
ADMINISTRATOR:MURILLO, GRABIELAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 360-8755
CITY:SAN JOSESTATE: CAZIP CODE:
95111
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
05/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Gabriela MurilloTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elizabeth Berumen met with Licensee, Gabriela Murillo
for an unannounced Required – 1 year annual inspection. LPA was granted access to the home by the Licensee. LPA also observed 8 day care children (one infant and 7 preschoolers) and Assistant, Maribel Oropeza Rodriguez in the home during today's inspection. Licensee was operating within her capacity and ratio requirements. LPA observed the required postings, including the facility license, near the front entrance to the home. Days and hours of operation are Monday - Friday from 7:00 AM to 5:30 PM. The adults residing in the home are: Licensee, Alex Murillo (son) and minor 17 year old daughter. Daughter turns 18 in October 2022.

LPA reviewed a Child Care Facility Roster; Roster is complete. LPA observed Fire/Disaster drill log during today's inspection; last practiced drill was 10/29/21. Licensee was reminded that she is to practice fire disaster drills once every 6 months and document them. Licensee's cpr & first aid is valid and expires on 10/22/22. Licensee has the required vaccines (MMR, Tdap, & flu). Licensee has the Mandated Reporter Training for Child Care Workers; completed on 10/22/2021. LPA reviewed eight children's files.
LPA inspected the indoor and outdoor areas of the home during today's inspection. Licensee has a working telephone in the home. The home is clean, orderly and safe for the day care children. LPA notes that the day care room is a little warm; there are no windows. Licensee states there is central A/C and understands that she to provide ventilation for safety and comfort. There are safe & age appropriate toys, play equipment, and materials for the children in the home. LPA did not observe any wall heaters inside the home. Off limit areas inside the home: 4 bedroom, kitchen, two bathrooms. Licensee uses a day care room; entrance is on the side of the home. Backyard is fenced.
LPA observed a fully charged 3A40BC fire extinguisher, working smoke/carbon monoxide detectors and no bodies of water. The Licensee states that she does not have any pets or weapons in the home. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children in the garage. Licensee understands that poisons are to be locked. Licensee states that she does not administer any medications to the day care children. Licensee states that nobody smokes and she understands that smoking is prohibited in the home.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Elizabeth Berumen
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2022
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: MURILLO, GRABIELA
FACILITY NUMBER: 434402998
VISIT DATE: 05/05/2022
NARRATIVE
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Supervision of children was discussed with the Licensee and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. Licensee understands her capacity/ratio options and she understands that she cannot have more than 14 children present in the home with qualified adult. Licensee states that a child will be isolated in the living room area if necessary due to illness or communicable disease. Licensee states that does not transport any day care children. Licensee understands that children shall not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.

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. Licensee states that Karen Hernandez stopped working with her in December 2020.

LPA discussed the safe sleep regulations with the 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 the 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.

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 [email protected]. 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

Exit interview conducted and report was reviewed with the Licensee, Gabriela Murillo. Deficiencies issued during today's inspection are documented on 809D.

[email protected]

A Notice of Site Visit was given and must remain posted for 30 days.

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Elizabeth Berumen
LICENSING EVALUATOR SIGNATURE:

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

DATE: 05/05/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 05/06/2022 08:29 AM - It Cannot Be Edited


Created By: Elizabeth Berumen On 05/05/2022 at 12:17 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MURILLO, GRABIELA
FACILITY NUMBER: 434402998

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.1(a)(10)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information: (10) A signed and dated copy of the Notice of Employee Rights [LIC 9052, (Rev. 03/03)] as required by Section 102416(a) and Section 102417.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Licensee's assistant is missing the employee rights form which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2022
Plan of Correction
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Licensee agrees to submit a copy of completed LIC 9052 for Assitant (Maribel Rodriguez Oropeza) and also file in assitants file.
Type B
Section Cited
CCR
102416.1(a)(11)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information: (11) A signed statement regarding their criminal record history as required by Section 102370(c).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above; assitant (Maribel Rodriguez Oropeza) is missing a criminal record statement in her file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2022
Plan of Correction
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Licensee agrees to submit a copy of completed LIC 508 for Assitant (Maribel ) and also file in assitants file.
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:Mary Segura
LICENSING EVALUATOR NAME:Elizabeth Berumen
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 05/06/2022 08:29 AM - It Cannot Be Edited


Created By: Elizabeth Berumen On 05/05/2022 at 12:17 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MURILLO, GRABIELA
FACILITY NUMBER: 434402998

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above child 6 and 7 do not have immunization records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2022
Plan of Correction
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Licensee agrees to sumbit a copy of immunization records for child 6 and 7.
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:Mary Segura
LICENSING EVALUATOR NAME:Elizabeth Berumen
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2022


LIC809 (FAS) - (06/04)
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