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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434411478
Report Date: 11/29/2022
Date Signed: 11/29/2022 03:22:05 PM

Document Has Been Signed on 11/29/2022 03:22 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:GARCIA, MARIAFACILITY NUMBER:
434411478
ADMINISTRATOR:GARCIA, MARIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 665-5792
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 4DATE:
11/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Maria GarciaTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Required 1 Year inspection. LPA met with Licensee Maria Garcia and explained the reason for the inspection. Present during today's inspection were Licensee, her two adult daughters, who help with the family child care, and four children, whom 2 were infant age.

License and Notification of Parents Rights were observed to be posted. There is working phone at the home. The hours of operation are Monday through Friday 4:30AM to 4PM.

LPA toured the inside and outside of the home with Licensee. The off-limit areas of the home are four bedrooms, the bathroom next to the daycare room, and the backyard. There is fireplace, which is barricaded. Disinfectant, cleaning supplies, and other items that could pose a risk to children were inaccessible to children. LPA observed that there was a pack of Lysol wipes on the changing table, which is accessible to children. LPA also observed that there was a bucket of paint and a blender on top of the dryer, which is accessible to children. Licensee moved items where it is inaccessible to children during inspection. There are toys and equipment for children, which were age appropriate. There is fully charged fire extinguisher, smoke detector, and carbon monoxide detector. The last disaster drill was conducted on 10/10/2022. Licensee stated that there are no weapons, such as firearms, stored in the home.

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SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: GARCIA, MARIA
FACILITY NUMBER: 434411478
VISIT DATE: 11/29/2022
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------------------continuation of 809 dated 11/29/2022 page 1---------------------

Licensee only uses her front yard, which is fenced. There were no bodies of water observed during today's inspection. LPA observed that the bottom step of one of the plastic play structure was crack. It was not sharp. Licensee placed duck tape over the crack during inspection. LPA reminded Licensee to check that any plastic play structure has no cracks or broken and that any wooden benches are not sharp. LPA also reminded Licensee to dump out any water that collects.

Licensee checks infants while they are napping, but does not document that the 15 minute checks. 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.

Licensee does not provide Incidental Medical Services (IMS). Incidental Medical Services (IMS) policy was discussed. For IMS information , see PIN 22-02-CCP. 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: http://www.ada.gov/childqanda.htm

Licensee does not transport children, but understands that children cannot be left alone and unattended in parked vehicles.
----------------------continues on 809 dated 11/29/2022 page 3--------------------
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
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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: GARCIA, MARIA
FACILITY NUMBER: 434411478
VISIT DATE: 11/29/2022
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A copy of the facility roster was obtained. Four (4) children's files were reviewed during today's inspection. The records reviewed include but not limited to immunization records, LIC 282, and LIC 9227. LPA observed that C-1, C-2, and C-3 did not have section B filled out of the LIC 282. Licensee will have parent fill out LIC 282 and send proof to Licensing. LPA also observed that C-3 did not have LIC 9227 in file. Licensee will have parent fill out form and send proof to Licensing. LPA reminded Licensee to ensure that forms are filled out completely and are receiving all pages. C-4 had the top portion of the LIC 995 and LIC 9150, but the did not have the bottom portion. Licensee will obtain the bottom portion and send proof to Licensing.

Licensee and her assistants' files were also reviewed. Licensee and her assistant completed the Mandated Reported Reporter training on 01/2022. Licensee and her assistants have a valid CPR/1st Aid, which expires on 01/2023. A-1 did not have immunization records for measles and pertussis on file. Licensee stated that A-1 will obtain records and send proof to Licensing. LPA discussed with Licensee the forms that needs to be assistant's files, such as LIC 508 and LIC 9108.

The adults living in the home are Licensee and three of her adult children. Licensee also has one minor child. All adults have cleared fingerprints. A-2 does not have TB test results on file. Licensee stated that she will have A-2 obtain TB test results and send it to Licensing. 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.

-----------------continues on 809 dated 11/29/2022 page 4------------------------
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
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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: GARCIA, MARIA
FACILITY NUMBER: 434411478
VISIT DATE: 11/29/2022
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Licensee will submit the following:
- Sleep log for infants
- LIC 9227 for C-3
- LIC 995 and LIC 9150 for C-4
- Immunization records for Measles and pertussis for A-1
- TB test for A-2

As a result of this inspection, two Type B citations were issued. Exit interview was conducted and report was reviewed with Licensee Maria Garcia. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
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Document Has Been Signed on 11/29/2022 03:22 PM - It Cannot Be Edited


Created By: Samantha Yip On 11/29/2022 at 12:31 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: GARCIA, MARIA
FACILITY NUMBER: 434411478

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above in 1 out of 1 persons, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2022
Plan of Correction
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By POC 12/06/2022, Licensee stated that she will have parent fill out form and send proof to Licensing.
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 2 out of 2 persons, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2022
Plan of Correction
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By POC 12/06/2022, Licensee will document the time that infant was checked every 15 minutes and send proof to Licensing.
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:Joel Segura
LICENSING EVALUATOR NAME:Samantha Yip
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2022


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