274412287-6-25-2021-07-CC-SCES-C4BLSM-20210625090054

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 274412287
Report Date: 06/22/2021
Date Signed: 06/25/2021 09:00:59 AM

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:	CASTILLO-URENA, ADRIANNA		FACILITY NUMBER:	274412287
ADMINISTRATOR:	CASTILLO-URENA, ADRIANNA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(831) 578-9340
CITY:	SOLEDAD	STATE: CA	ZIP CODE:	93960
CAPACITY:	14	CENSUS: 6	DATE:	06/22/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Adrianna Castillo-Urena		TIME COMPLETED:	02:10 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 06/22/2021 at 01:00 PM, Licensing Program Analyst (LPA) Susy Cervantes met with licensee Adrianna Castillo-Urena for an annual/random inspection and explained the nature of today’s visit. Present during today’s visit were Licensee, their 13 year old daughter with 6 children: 2 school age and 4 preschool. Adults living in the home are licensee with two children ages 15 and 13. Days and hours of operation are Monday through Friday, 5:00 am to 6:00 pm. A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 06/17/2021 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 heaters, and barricaded stairs. Off limits indoor: second floor and garage. There are no bodies of water. Licensee stated there are no firearms/weapons in the home. There was a dog, licensee stated they are vaccinated. LPA observed a 2A10BC fire extinguisher that was fully charged. 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 in the top kitchen cabinet and under the kitchen sink, both locations have magnet locks. Backyard is fenced. Off limits outdoor: Left side yards and locked shed. LPA reminded licensee that she can only have 14 children according to her license. Children were supervised during the visit and LPA went over substitute options. *Continues on report dated 06/09/2021 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: 06/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021

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: CASTILLO-URENA, ADRIANNA	FACILITY NUMBER: 274412287
	VISIT DATE: 06/22/2021

NARRATIVE

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Licensee stated that 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.

LPA took a picture of a current roster of the children. LPA observed a fire and disaster drill log that was last conducted on 06/22/2021. LPA reviewed 4 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 was discussed. LPA observed that the Licensee has completed Mandated Reporter training on 07/25/2019. Licensee has Pediatric CPR/1^st Aid expiring 06/22. Needed documentation for SB 792 which requires immunization against Pertussis, Measles, and Influenza (decline statement) as well as TB testing is on file for licensee.

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 immediate civil penalties for Zero Tolerance of $500 and the Healthy Beverage Act and AB633 requirements for type A violation. 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 provided a copy of the “Lead Poisoning Facts Information Flyer” to the facility. Safe sleep was discussed with the Licensee and Guide to Safe Sleep information was provided to the 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 may 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: 06/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021

LIC809 (FAS) - (06/04)

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