274414462-12-9-2021-07-CC-SCES-C9JPVF-20211209103903

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 274414462
Report Date: 12/09/2021
Date Signed: 12/09/2021 10:39:10 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:	LOPEZ, MARIA LOURDES		FACILITY NUMBER:	274414462
ADMINISTRATOR:	LOPEZ, MARIA LOURDES		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(831) 214-7672
CITY:	KING CITY	STATE: CA	ZIP CODE:	93930
CAPACITY:	14	CENSUS: 0	DATE:	12/09/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:35 AM
MET WITH:	Maria Lourdes Lopez		TIME COMPLETED:	10:45 AM

NARRATIVE

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On 12/09/2021 at 08:35 AM, Licensing Program Analyst (LPA) Susy Cervantes met with licensee, Maria Lourdes Lopez, for an annual inspection and explained the reason for the visit to them. Present during today's visit were licensee and their daughter. Adults living in the home are licensee, their spouse, and two adult daughters. Days and hours of operation are Monday through Saturday 5:00 AM to 4:00 AM.

A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 12/06/2021 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. 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 covered fire place, no wall heater, no stairs, and no bodies of water. Licensee stated there are no weapons and three dogs that are vaccinated in the facility. LPA observed a 2A10BC fire extinguisher that was last serviced on 02/04/2021. 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. SIde and front yard is fenced. Off limit areas: 3 bedrooms, one bathroom, kitchen, garage, and back yard.

LPA went over substitute options and reminded licensee they could only have 14 children according to their license. 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 12/09/2021 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: 12/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021

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: LOPEZ, MARIA LOURDES	FACILITY NUMBER: 274414462
	VISIT DATE: 12/09/2021

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Continuation of report dated 12/09/2021 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 10/15/21. LPA reviewed 10 children’s files and observed a copy of the emergency information card (LIC 700) and an 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 has Mandated Reporter training, training was completed on 03/26/21. Licensee has Pediatric CPR/1^st Aid expiring 02/01/23. Needed documentation for SB 792 which requires immunization against Pertussis, Measles, and Influenza 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.

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.

No deficiencies were 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 Maria Lourdes Lopez. A notice of site visit was given and 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: 12/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021

LIC809 (FAS) - (06/04)

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