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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416299
Report Date: 02/02/2023
Date Signed: 02/03/2023 09:04:10 AM

Document Has Been Signed on 02/03/2023 09:04 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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:LAZO SAMANIEGO, HERLINDAFACILITY NUMBER:
434416299
ADMINISTRATOR:LAZO SAMANIEGO, H.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(669) 278-5143
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
02/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Herlinda Lazo TIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analysts (LPA's) Anna Morales and Farida Raja conducted an ANNUAL REQUIRED inspection and was greeted by Licensee Herlinda Lazo and one staff. Present were four children ( two infants and two preschool aged children) who were napping. Licensee and another adult resides in the home. Days and hours of operation are Monday - Friday from from 12am to 11:00pm. LPA's reviewed a current Child Care Facility Roster and observed a Fire/Disaster drill log during today's inspection. The last fire drill was conducted on 6/3/2022.

LPA's toured the indoor and outdoor areas of the home during today's inspection. The Licensee’s has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children. The home is clean, orderly, and safe for the day care children. LPA's observed smoke/carbon detectors and a fire extinguisher. The facility is a single story home. Off limit areas inside the home: the master bedroom. laundry area and one closet, attached driveway and storage shed In the backyard, LPA observed a covered sandbox, and other play structures. There is a fence surrounding the house. There is a patio above the sandbox. LPA's did not observe any bodies of water. Licensee stated that she does not have weapons on premises.

LPA's 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. (page 1)
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: LAZO SAMANIEGO, HERLINDA
FACILITY NUMBER: 434416299
VISIT DATE: 02/02/2023
NARRATIVE
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Incidental Medical Services (IMS) policy was discussed. Licensees stated that she does not take care of any children who are ill. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. Licensee have an area where sick children can be isolated from the others until parent pick-up.

Licensees Mandated Reporter Training (AB1207). is current. LPA's discussed Senate Bill 792, Assembly Bill (AB) 1207 (Mandated Child Abuse Reporting Training) which is required training that began on January 1, 2018 and requires renewal every two years, AB 633 was discussed with applicant Licensing forms, Title 22 regulations, can be obtained through the internet at www.ccld.ca.gov. Mandated Reported Training can be accessed at www.mandatedreporterca.com.

A random selection of children’s files were reviewed during todays inspection for the following records: Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), and Immunization Records (PM286). LPA's did not observe a Individual Infant Sleeping Plan(LIC9227) for one of the infants who is under twelve months. LPA's, also, did not observe a 15 minute check form/documentation for a sleeping infant (over twelve month, under two years of age). LPA's also did not observe a copy of one of the infants immunization record.

Licensee and two staff files were reviewed for the following records: Employee Rights (LIC9052), Criminal Record Statement (LIC508), Statement Acknowledging Requirement to report Child Abuse (LIC9108), and Immunization Record showing immunity to measles (MMR), pertussis (Tdap), and influenza (or statement declining influenza). Licensee and the two staff have a current First Aid/CPR
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023
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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: LAZO SAMANIEGO, HERLINDA
FACILITY NUMBER: 434416299
VISIT DATE: 02/02/2023
NARRATIVE
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LPA's reminded Licensee of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who comes in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12- month period.

LPA's discussed the requirements of AB 633 with the Licensee and understands the AB 633 fact sheet/copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224). LPA discussed "zero tolerance" related regulations and advised that the assessment of an immediate $500 per day civil penalty for any violation of a "zero tolerance" related regulation. An ongoing civil penalty of $100 per day continues until the violation(s) is corrected.

Exit Interview was conducted with Licensee. Deficiencies are being cited based on the LPA's observations, interviews conducted and records reviewed in accordance with the California Code of Regulations Title 22.

LPA was unable to leave a copy of this report due to technical difficulties. LPA will also submit a copy of the NOTICE OF SITE VISIT. Licensee will post this form near the entrance to the home and must remain posted for 30 days.

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/inspection-process
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 02/03/2023 09:04 AM - It Cannot Be Edited


Created By: Anna Morales On 02/02/2023 at 03:26 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: LAZO SAMANIEGO, HERLINDA
FACILITY NUMBER: 434416299

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

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. Licensee stated that she has not completed an Disaster drill since June 3, 2022, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/23/2023
Plan of Correction
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Licensee stated that she will conduct an emergency disaster plan and submit a copy of the plan to CCL by the POC due date
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document 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 Licensee stated that she did not record for every 15 minutes for C1 was sleeping which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/23/2023
Plan of Correction
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Licensee stated that she will send a plan to ensure that 15 minute checks are conducted.
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:Gladys Kuizon
LICENSING EVALUATOR NAME:Anna Morales
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2023


LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 02/03/2023 09:04 AM - It Cannot Be Edited


Created By: Anna Morales On 02/02/2023 at 03:26 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: LAZO SAMANIEGO, HERLINDA
FACILITY NUMBER: 434416299

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2023

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. Licensing Program Analysts (LPA's) did not observe C3 immunizations records, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/23/2023
Plan of Correction
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Licensee stated that she will submit a copy of C3 immunizations to CCL by the POC date
Type B
Section Cited
CCR
102425(c)(2)
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. The Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be maintained in the infant’s file and shall be available to the Department for review.

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. LIcensee stated that she did not have an Individual Infant Sleeping Plan for C3, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/23/2023
Plan of Correction
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Licensee stated that she will submit a copy of the Individual Infant Sleeping Plan (LIC9227) by the POC date to CCL.
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:Gladys Kuizon
LICENSING EVALUATOR NAME:Anna Morales
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2023


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