270766755-10-5-2021-07-CC-SCES-C7HUMN-20211005154238

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 270766755
Report Date: 10/05/2021
Date Signed: 10/05/2021 03:42:46 PM

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:	BANUELOS, BELEN		FACILITY NUMBER:	270766755
ADMINISTRATOR:	BANUELOS, BELEN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(831) 675-3929
CITY:	GONZALES	STATE: CA	ZIP CODE:	93926
CAPACITY:	12	CENSUS: 8	DATE:	10/05/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Belen Banuelos		TIME COMPLETED:	03:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 10/05/2021 at 02:15 PM, Licensing Program Analyst (LPA) Susy Cervantes met with licensee, Belen Banuelos, for an annual inspection and explained the nature of today’s visit. Present during today’s visit were Licensee and their daughter/assistant, Katelyn, with 8 preschool age children. Adults living in the home are licensee and their spouse with one child age 16. Days and hours of operation are Monday through Friday, 7:00 am to 5:30 pm. A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 10/04/2021 was reviewed; and it indicates that all Facility staff or other individuals who require caregiver background clearances have received criminal record and child abuse index clearances or exemptions. LPA reminded Licensee of the applicable civil penalties for those adults who have not received fingerprint clearance, are not associated to the license and who come in contact with or provide care and supervision to the children. Penalty amounts: $100 per person per day, minimum of $100 to a maximum of $500 per person for an initial violation, and a minimum of $100 to a maximum of $3000 per person for any subsequent violation within a 12-month period. LPA toured the inside and outside of the home. LPA observed a covered fireplace, no wall heater, and no stairs. Off limits indoor: four bedrooms and one bathroom. There are no bodies of water. Licensee stated there is one dog and they are vaccinated. Licensee stated there are no weapons in the home. LPA observed a 3A40BC fire extinguisher that was last serviced on 08/20/21. Smoke detector and Carbon Monoxide detectors are operable. Telephone is in working order. Sharp objects, medicines, poisons and cleaning supplies are inaccessible to the children and stored on a top bathroom shelf in the daycare room. Front yard is fenced. Off limits outdoor: garage and backyard that is fenced off. LPA reminded licensee that she can only have 14 children according to their license. *Continues on report dated 10/05/2021 pg. 1/2*

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Susy Cervantes	TELEPHONE: (408) 598-9403
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021

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: BANUELOS, BELEN	FACILITY NUMBER: 270766755
	VISIT DATE: 10/05/2021

NARRATIVE

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Continuation of report dated 10/05/2021 pg. 2/2
Children were supervised during the visit and LPA went over substitute options. Licensee stated they do not transport children, LPA reminded Licensee that children are never to be left in parked vehicles and must use appropriate car seats according to the child's age/weight/size.

LPA received a copy of a current roster of the children. LPA observed a fire and disaster drill log that was last conducted on 03/15/21. LPA reviewed 8 children’s files and observed a copy of the emergency information card (LIC 700) in each file. Infant individual sleeping plan (LIC 9227) for each infant under 12 months and a 15 minute check sleep log for infants under 24 months was discussed with Licensee. LPA observed that the Licensee and assistant have completed Mandated Reporter training on 10/18/19. Licensee and assistant have Pediatric CPR/1^st Aid expiring 08/23. LPA received a copy of needed documentation for SB 792 which requires immunization against Pertussis, Measles, and Influenza as well as TB testing for licensee and assistant.

Incidental Medical Services (IMS) policy was discussed with the licensee. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The licensee is not providing IMS at this time. Licensee will submit an updated plan of operation if in the future they provide any IMS services to a child in care.

Licensee was reminded that any authorized employee of the Department may enter and inspect any place providing personal care and services at any time, with or without advance notice. LPA discussed the requirements of AB 633 with the Licensee, Belen Banuelos, and provided the AB 633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and they understand the requirements. LPA also discussed "zero tolerance" related regulations with the Licensee and was advised of the assessment for 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. Beginning January 1, 2019 AB2370 requires licensed homes and centers to share information on the risks and effects of lead exposure with enrolling and re-enrolling families. LPA discussed the “Lead Poisoning Facts Information Flyer” with licensee. Department website: http://ccld.ca.gov provided to Licensee. Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction Due Date will result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.

An exit interview was conducted with Licensee. No deficiencies were cited during today’s inspection. Notice of site visit must remain posted for 30 days.

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Susy Cervantes	TELEPHONE: (408) 598-9403
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021

LIC809 (FAS) - (06/04)

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