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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075700205
Report Date: 10/24/2022
Date Signed: 10/24/2022 03:59:12 PM


Document Has Been Signed on 10/24/2022 03:59 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612



FACILITY NAME:JIMENEZ, KARINAFACILITY NUMBER:
075700205
ADMINISTRATOR:JIMENEZ, KARINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 248-3508
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY:14CENSUS: 10DATE:
10/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Karina JimenezTIME COMPLETED:
04:10 PM
NARRATIVE
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On October 24, 2022, at 12:30pm, Licensing Program Analyst (LPA) Julia Placencia arrived unannounced for a Required-1 Year Inspection, and met with Licensee Karina Jimenez. Present today were ten children (four infants and six preschoolers) and two helpers (Carola Duarte and Claudia Quiroz) At 12:45pm, the home was toured with the licensee to conduct a health and safety inspection. Hours of operation for child care are Monday through Friday, 7:30am to 5:30pm.

ON LIMITS: Two child care rooms at front of house, first bedroom to the right in hallway for napping infant(s) in pack-n-plays, hallway bathroom, backyard.

OFF LIMITS: Kitchen, family room, remaining three bedrooms including master bathroom, garage, gated side and rear portions of backyard. Off limit areas are inaccessible by closed and/or locked doors and visual supervision. Licensee is aware she must contact Licensing so that an inspection can be completed prior to changing an off limits area to on limits.

The home is single story, which is neat and clean, with heating and ventilation for safety and comfort. The large outdoor play area is fenced, and free from defects and dangerous conditions. There were ample age appropriate toys that were observed to be safe and in good condition. Toxins, medicines, and hazardous items were inaccessible during today's inspection. Fire extinguisher, carbon monoxide and smoke detector meet State Fire Marshall standards. The fireplace is in the off-limits family room. Per licensee, there are no firearms in the home. The licensee conducts and documents Fire/Disaster Drills at least twice a year, and the log indicates a drill was conducted 10/21/22. All required licensing documents are posted and visible for public review.


***Continued on LIC 809C...
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Julia PlacenciaTELEPHONE: (510) 725-5998
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2022
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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: JIMENEZ, KARINA
FACILITY NUMBER: 075700205
VISIT DATE: 10/24/2022
NARRATIVE
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At 1:45pm children's files were reviewed. The facility roster was reviewed, and a copy obtained. The licensee is in ratio today. LIcensee has day care insurance. The licensee's Pediatric CPR/First Aid certificate is current and expires 4/24/23. Licensee is in compliance with the immunization law. Licensee's mandated reporter training was completed on 10/1/21.

Incidental Medical Services (IMS) policy was discussed. 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. 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 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 was encouraged to frequently visit our website at www.ccld.ca.gov for licensing regulations and updates, and to also email childcareadvocatesprogram@dss.ca.gov to be included in the Child Care Quarterly Updates distribution list.



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 [facility representative] 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.

***Continued on LIC 809C...

SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Julia PlacenciaTELEPHONE: (510) 725-5998
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022
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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: JIMENEZ, KARINA
FACILITY NUMBER: 075700205
VISIT DATE: 10/24/2022
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**The following deficiency were observed during today's inspection:
  • LPA observed both helpers present today do not have proof of measles and pertussis.

See 809D for deficiencies cited today. Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.
Please also see LIC 9102 for Advisory Notes.

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 inspectionprocess@dss.ca.gov. 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.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee Karina Jimenez.

SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Julia PlacenciaTELEPHONE: (510) 725-5998
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 10/24/2022 03:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612


FACILITY NAME: JIMENEZ, KARINA
FACILITY NUMBER: 075700205

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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1597.622(a)(1) Employees or volunteers at family day care home; immunization requirements; records; exemptions -
Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. This requirement is not met as evidenced by: Both helpers present today do not have proof of measles, pertussis and flu immunizations in their files, which poses a potential health and safety risk to children in care.
POC Due Date: 11/07/2022
Plan of Correction
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By POC date of 11/7/22, licensee shall obtain proof of measles, pertussis and flu from helpers and submit copies to LPA. Staff may decline flu vaccination by writing a letter.
***Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.
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: Jason JangTELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Julia PlacenciaTELEPHONE: (510) 725-5998
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2022
LIC809 (FAS) - (06/04)
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