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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274405087
Report Date: 10/20/2021
Date Signed: 10/20/2021 03:41:16 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:ORTIZ, MARIA & ROCHA, JOSEFACILITY NUMBER:
274405087
ADMINISTRATOR:ORTIZ, MARIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 633-8721
CITY:CASTROVILLESTATE: CAZIP CODE:
95012
CAPACITY:14CENSUS: 4DATE:
10/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Maria OrtizTIME COMPLETED:
03:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Fermin Campos-Jaramillo conducted an unannounced annual required inspection to the home today. LPA met with Maria Ortiz, licensee, and explained the nature of today's inspection to her. Days and hours of operation are Monday to Friday from 6:00 AM to 6:00 PM.The adults that reside in the home are the licensees Maria and Jose. There were four children in care during the inspection included one infant and three preschool age. Licensees' certifications for CPR and First Aid are current and will expire on 1/31/22 for both licensees.
LPA toured the indoor and outdoor areas of the home during today's inspection. LPA obtained a copy of the Child Care Facility Roster during today's inspection and it is current. Licensee reviewed five children's files and they are complete. LPA reviewed the Fire/Disaster drill log during today's visit and it is current. Last fire drill was documented on 9/28/21. Licensee understand a fire drill shall be performed and documented at least one every six months.
The Licensee has a working telephone (landline) in the home. LPA observed sufficient materials, toys, and play equipment for the day care children. Off limit areas inside are: 3 bedrooms, and 1 bathroom. LPA observed there are no stairs in the home. Licensees understand the converted garage can not be used as primary childcare area. The home has a fireplace which is barricaded. The off limits area outside the home is a shed in the backyard and the left side yard. LPA observed the home has a back yard and it is fenced. Licensees use part of the back yard and the right side yard as playground when the weather is good.
LPA observed a fully charged 3A40BC fire extinguisher last time serviced on 8/25/21, working smoke detectors and no bodies of water. LPA observed the home has at least one carbon monoxide detector. The Licensee states that she does not have any weapons in the home. All detergents, cleaning compounds, medications, and other similar items are stored inaccessible to children.
Licensees have submitted before proof of having immunization for measles, pertussis for both of them and a signed opt out statement for influenza for both licensees.
***************************Report dated 10/20/21 continues on page 2.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Fermin Campos-JaramilloTELEPHONE: 408-334-8557
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 4
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: ORTIZ, MARIA & ROCHA, JOSE
FACILITY NUMBER: 274405087
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2021

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 file review the licensee did not comply with the section cited above in the documents in file for one infant in care which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2021
Plan of Correction
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Licensee shall fill out form LIC9227 for the infant in care and obtain signatures from parents/representatives and will submit a copy to Licensing Department not later than November 3, 2021.
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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Fermin Campos-JaramilloTELEPHONE: 408-334-8557
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: ORTIZ, MARIA & ROCHA, JOSE
FACILITY NUMBER: 274405087
VISIT DATE: 10/20/2021
NARRATIVE
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Report dated 10/20/21 continues from page 1.

A review of staff records on 10/19/21 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee Maria 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.

Supervision of children was discussed with the Licensee and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. The Licensees understand their capacity options and they understand that they cannot have more than 14 children in the home at any time and a helper must be present. Licensees understand that in absence of a helper her license capacity is reduced to only 8 children, and ratio must be observed. The Licensees stated that they do not transport children via vehicle and they understand that children cannot be left in parked vehicles unattended at any time.

Department website: www.ccld.ca.gov provided to Licensee.


Licensees have proof of completion of the required "mandated reporter" training on 7/23/21 LPA referred the Licensee to the training website: www.mandatedreporterca.com for additional information on the online training.
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.

Report continues on page 3.

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Fermin Campos-JaramilloTELEPHONE: 408-334-8557
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: ORTIZ, MARIA & ROCHA, JOSE
FACILITY NUMBER: 274405087
VISIT DATE: 10/20/2021
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Report continues from page 2.
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

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.

Exit interview conducted and report was reviewed with the licensee Maria Ortiz.

One type B deficiency was cited.

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

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Fermin Campos-JaramilloTELEPHONE: 408-334-8557
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4