274408976-4-28-2022-07-CC-SCES-CDWQSA-20220428122514

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 274408976
Report Date: 04/28/2022
Date Signed: 04/28/2022 12:25:20 PM

Document Has Been Signed on 04/28/2022 12:25 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:	JIMENEZ, ELVIA		FACILITY NUMBER:	274408976
ADMINISTRATOR:	ELVIA JIMENEZ		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(831) 444-9792
CITY:	SALINAS	STATE: CA	ZIP CODE:	93906
CAPACITY:	14	CENSUS: 10	DATE:	04/28/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Elvia Jimenez		TIME COMPLETED:	12:30 PM

NARRATIVE

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On 04/28/2022 at 09:00 AM, Licensing Program Analyst (LPA) Susy Cervantes met with licensee, Elvia Jimenez, for an annual inspection and explained the reason for the visit to them. Present during today's visit were licensee and her assistants with 10 children: six preschool and four infants. Adults living in the home are licensee, their spouse and son. Days and hours of operation are Monday through Friday 6:00 AM to 6:00 PM.

A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 03/16/2022 was reviewed and it indicates that not all Facility staff or other individuals who require caregiver background clearances have received criminal record and child abuse index clearances or exemptions, one of the assistants is not CACI cleared. 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.

LPA inspected inside and outside of the home. LPA observed a no fireplace, no wall heater, no stairs, and no bodies of water. Licensee stated there are no weapons and no pets. LPA observed a 3A40BC fire extinguisher that was serviced on 04/01/2022. Carbon Monoxide detector and smoke detectors were operable. Sharp objects, medicines, poisons and cleaning supplies are inaccessible to the children and stored in the garage and top kitchen cabinet. Front and back yard are fenced. Off limit areas: three bedrooms, one bathroom, garage, left side yard and two sheds.

Children were supervised during the visit and LPA went over substitute options and reminded licensee they could only have 14 children according to their license with an assistant. 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.

Continues on report dated 04/28/2022 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: 04/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022

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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Document Has Been Signed on 04/28/2022 12:25 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: JIMENEZ, ELVIA	FACILITY NUMBER: 274408976
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102370(d)(1)

Criminal Record Clearance

(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in which assistant's fingerprints have not been CACI cleared which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/12/2022
	Plan of Correction
1 2 3 4	Assistant will get re-fingerprinted and licensee will send receipt/proof of completion to the San Jose Regional Office by close of business on May 12, 2022.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Susy Cervantes	TELEPHONE: (408) 598-9403
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022

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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: JIMENEZ, ELVIA	FACILITY NUMBER: 274408976
	VISIT DATE: 04/28/2022

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Continuation of report dated 04/28/2022 pg. 2/2

LPA took a picture of a current roster of the children. LPA observed a fire and disaster drill log that was last conducted on 04/01/22. LPA reviewed 12 children’s files and observed all required documentation was in compliance as well as Infant individual sleeping plan (LIC 9227) for each infant under 12 months and a 15 minute check sleep log for infants under 24 months. LPA observed that the Licensee and assistants have Mandated Reporter training, training was completed on 08/03/20, 03/20/22, and 01/21/22. Licensee and assistant have Pediatric CPR/1^st Aid expiring 11/27/23, 03/2024, 11/23/23. Needed documentation for SB 792 which requires immunization against Pertussis, Measles, and Influenza as well as TB testing is on file for licensee, LPA reviewed immunizations for assistants and were in compliance.

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.

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.

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.

Type B deficiency was cited during today's visit. 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. Exit interview conducted and report was reviewed in Spanish with the licensee, Elvia Jimenez. 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.

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Susy Cervantes	TELEPHONE: (408) 598-9403
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022

LIC809 (FAS) - (06/04)

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