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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274409442
Report Date: 08/10/2023
Date Signed: 08/10/2023 01:10:55 PM


Document Has Been Signed on 08/10/2023 01:10 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:GARCIA, BERTHAFACILITY NUMBER:
274409442
ADMINISTRATOR:GARCIA, BERTHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 206-5895
CITY:SALINASSTATE: CAZIP CODE:
93906
CAPACITY:14CENSUS: 6DATE:
08/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:36 AM
MET WITH:Bertha GarciaTIME COMPLETED:
01:30 PM
NARRATIVE
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On 08/10/23 at 08:36 AM, Licensing Program Analyst (LPA) Teodoro Trujillo met with licensee, Bertha Garcia for an annual inspection and explained the reason for the visit. Present during today's visit were licensee and assistant Guadalupe with 6 children: five preschool and one infant. Adults living in the home are licensee, and her spouse. 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 07/10/2023 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. 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 no wall heater and a barricaded fireplace in family room and fireplace in the living room with a metal screen cover, no stairs, and no bodies of water. Licensee stated there are no weapons. Licensee stated she has no pets. LPA observed a fully charged 3A40BC fire extinguisher. Carbon Monoxide detector and smoke detectors were operable. Medicines, poisons and cleaning supplies were accessible to the children and sharp objects are stored on the top kitchen cabinet. One (1) quart can of Paint thinner, 1 12-oz can of Rustoleum spray paint, and 1 spray can of disinfectant were observed in outside sink cabinet used by day care children. Off limit areas: Master bedroom and bathroom with attached garage. LPA observed a previously Office room is being used for napping children in care.

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. Licensee stated they do 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 08/10/2023 pg. 1/3
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023
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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: GARCIA, BERTHA
FACILITY NUMBER: 274409442
VISIT DATE: 08/10/2023
NARRATIVE
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Continuation of report dated 08/10/2023 pg. 2/3
LPA reviewed a current roster of the children. LPA observed a fire and disaster drill log that was last conducted on 07/21/2023. LPA reviewed 6 children’s files and observed not all required documentation was in compliance. Immunization Record CDPH 286 missing for C1, C2, C3, C4, C5, and C6. Parents Rights LIC995A missing for C4, sleep log and proof of immunization missing for C1.

Infant individual sleeping plan (LIC 9227) for each infant under 12 months was not provided and discussed 15 minute check sleep log for infants under 24 months missing for Child 1 (C1). LPA observed that the Licensee and assistant Guadalupe have Mandated Reporter training, training was completed on 5/15/2023. Licensee has Pediatric CPR/1st Aid expiring 08/24/24 and assistant Guadalupe 01/2025. Needed documentation for SB 792 which requires immunization against Pertussis, Measles, and Influenza as well as TB testing is on file for licensee. TB testing is missing for assistant Guadalupe.

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. PIN 22-02-CCP was discussed.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep web page 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 A deficiencies were cited during today's visit. LPA Teodoro Trujillo informed licensee Bertha Garcia that this report dated 08/10/2023 document(s) 1 (one) Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.


Continues on report dated 08/10/2023 pg. 2/3

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
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Document Has Been Signed on 08/10/2023 01:10 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: GARCIA, BERTHA
FACILITY NUMBER: 274409442

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(4)
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: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 1 quart can of Paint thinner, 1 12-oz can of Rustoleum spray paint, and 1 spray can of disinfectant in outside sink cabinet used by day care children which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/11/2023
Plan of Correction
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Licensee immediately removed items from outside sink cabinet and stored in off limit garage during site inspection.
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: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/10/2023 01:10 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: GARCIA, BERTHA
FACILITY NUMBER: 274409442

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.3(a)(6)
Alterations to Existing Building or Grounds
(a) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following: (6) Any change from an area of the family child care home previously identified as "off limits" to an area where care and supervision will be provided to children in care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in Off limit Office is being used for napping children in care, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2023
Plan of Correction
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Licensee will submit a new facility sketch and will send a written statement of her understanding of the regulation by close of business to the San Jose Regional Office 08/25/2023.
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 observation, interview and record review, the licensee did not comply with the section cited above in Child 1 (C1) missing proof of Immunization's, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2023
Plan of Correction
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Licensee corrected deficiency during site visit, C1 parent submitted proof of immunization to licensee during site visit.
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: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/10/2023 01:10 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: GARCIA, BERTHA
FACILITY NUMBER: 274409442

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in Documentation missing on CDPH 286 for Child 1 (C1), C2, C3, C4, C5 and C6, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2023
Plan of Correction
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Licensee will submit completed CDPH 286 for children in care to the San Jose Regional Office by close of business 08/25/2023.
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: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/10/2023 01:10 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: GARCIA, BERTHA
FACILITY NUMBER: 274409442

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in Missing LIC 995A for Child 4, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2023
Plan of Correction
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Licensee will submit a copy of signed LIC955A for Child 4, to the San Jose Regional Office by close of business 08/25/2023.

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: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/10/2023 01:10 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: GARCIA, BERTHA
FACILITY NUMBER: 274409442

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in Documentation of the 15-minute check is missing for Child 1, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2023
Plan of Correction
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Licensee will submit copies of documentation of Sleep logs for Infant Child 1 by close of business 08/25/2023.
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: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023
LIC809 (FAS) - (06/04)
Page: 7 of 11


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: GARCIA, BERTHA
FACILITY NUMBER: 274409442
VISIT DATE: 08/10/2023
NARRATIVE
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Continuation of report dated 08/10/2023 pg. 3/3

Also, LPA Teodoro Trujillo informed the licensee Bertha Garcia to provide a copy of this licensing report dated 08/10/2023 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

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, Bertha Garcia. 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 SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
LIC809 (FAS) - (06/04)
Page: 10 of 11
Document Has Been Signed on 08/10/2023 01:10 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: GARCIA, BERTHA
FACILITY NUMBER: 274409442

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102369(b)(9)


This requirement is not met as evidenced by:

102369 Application for Initial License

(9) Evidence of a current tuberculosis clearance, not more than one year prior to or seven days after initial presence in the home, for any adult in the home during the time that children are under care.
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in assistant Guadalupe does not have proof of TB testing, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2023
Plan of Correction
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Licensee will submit proof of TB testing for assistant Guadalupe by close of business 08/25/23 to the San Jose Regional Office.
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: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023
LIC809 (FAS) - (06/04)
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