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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434408932
Report Date: 09/23/2021
Date Signed: 09/23/2021 11:18:40 AM

Document Has Been Signed on 09/23/2021 11:18 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:BERMUDEZ, CLAUDIAFACILITY NUMBER:
434408932
ADMINISTRATOR:BERMUDEZ, CLAUDIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 979-0433
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 3DATE:
09/23/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:02 AM
MET WITH:Claudia BermudezTIME COMPLETED:
11:50 AM
NARRATIVE
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Licensing Program Analyst (LPA), Janette Cruz, met with Claudia Bermudez, Licensee for an unannounced case management inspection in response to a self-reported Unusual Incident that the Facility reported to the Department. LPA explained to Claudia the purpose of the visit and was granted access to the home.

The unusual incident occurred on 09/10/21, a dog named Shadow (black Labrador) that lives in Claudia's home bit one of the children. Claudia states that the kids were dancing and playing in the living room where the dog was sleeping on the couch. Claudia states that she went to the kitchen to get fruits to serve as snacks for the children and within a split second the dog reacted and bit the child (C1) in the face. Claudia states that she called C1's parents right away to have C1 picked up and be taken to the emergency room. Claudia states that she put an ice pack to C1's face while waiting for C1's parents to arrive because C1's face was already starting to get swollen. Claudia states that C1 was treated in the emergency room and sustained wounds that required three stitches, two on eyelid and one on the temple. LPA observed C1 today in the home with healing wounds on her left eye lid and temple.

LPA observed that the dog is locked in a kennel located inside the master's bedroom of the home which is off-limits to children. Claudia states that the dog has never had an incident of biting or snapping at anyone before but possibly that the dog could have had some pain from a recent surgery the day of the incident. Claudia states that the dog will be locked inside the master's bedroom and inaccessible to children during day care hours. Claudia states that she takes the dogs out to do its business through the access sliding door from the master's bedroom of the home during children's nap time. Claudia also states that her daughter also helps her taking the dog out if needed.

LPA observed that Licensee has another dog named Maverick (brown Golden Retriever) that is also kept locked in a kennel inside the master's bedroom. Claudia provided current rabies and other vaccination records for both dogs in the home.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2021
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: BERMUDEZ, CLAUDIA
FACILITY NUMBER: 434408932
VISIT DATE: 09/23/2021
NARRATIVE
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A "Type A" deficiency is being issued today, See (809-D page).

LPA discussed the requirements of AB633 to Licensee and provided her the AB633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and Licensee understands the requirements. Upon receipt, Licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.

A notice of site visit was issued and posted near the facility entrance along with the Type "A" citation and both notices must remain posted for 30 consecutive days. The Licensee must provide copies of this report to parents/guardians of children in care at this facility and to parents/guardians of children newly enrolled at this facility during the next 12 months.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/23/2021 11:18 AM - It Cannot Be Edited


Created By: Janette Cruz On 09/23/2021 at 10:21 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: BERMUDEZ, CLAUDIA
FACILITY NUMBER: 434408932

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/24/2021
Section Cited
CCR
102423(a)(2)

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102423(a)(2) Each child receiving services from a family child care home shall have certain rights including the right receive safe, healthful, and comfortable accommodations, furnishings, and equipment. This requirement is not met as evidenced by:
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Licensee will send a written report to Licensing by POC date 9/24/21 stating her plan to keep her dogs inaccessible to children during day care hours.
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Based on observations, interviews and record reviews, child (C1) did not receive safe accommodations when C1 was bitten by the dog on 9/10/21
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According to AB 633, parents must be provided with this report which contains this Type A deficiency for the next 12 months and copy of signed acknowledgement form must be kept in each child's file. LPA advised Licensee that an Office Meeting will be scheduled at a later date. Written notification of the office meeting will be sent to Licensee via mail.

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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:Diana Stephenson
LICENSING EVALUATOR NAME:Janette Cruz
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2021


LIC809 (FAS) - (06/04)
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