274414462-10-11-2022-07-CC-SCES-CK4TRL-20221011145744

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 274414462
Report Date: 10/11/2022
Date Signed: 10/11/2022 02:57:59 PM

Document Has Been Signed on 10/11/2022 02:57 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:	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: 8	DATE:	10/11/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Maria Lourdes Lopez		TIME COMPLETED:	03:15 PM

NARRATIVE

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On 10/11/2022 at 12:30 PM, 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 was licensee and an adult helper that has not been fingerprint cleared with 8 children: two infants and six preschool. Adults living in the home are licensee, their spouse and two daughters. Days and hours of operation are Monday through Friday 5:30 AM to 5:30 PM.

A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 10/11/2022 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. 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 blocked fireplace, no wall heater, no stairs, and no bodies of water. Licensee stated there are no weapons. Licensee stated they have dogs and they are vaccinated. LPA observed a 2A10BC fire extinguisher that was serviced on 02/09/22. Dual Carbon Monoxide and smoke detector was operable. Sharp objects, medicines, poisons and cleaning supplies are inaccessible to the children and stored in the garage. Sideyard is fenced. Off limit areas: three bedrooms, one bathroom, garage, back yard, and left side yard.

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.

Continues on report dated 10/11/2022 pg. 1/3

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Susy Cervantes	TELEPHONE: (408) 598-9403
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022

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 10/11/2022 02:57 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: LOPEZ, MARIA LOURDES	FACILITY NUMBER: 274414462
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

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 interview and record review, the licensee did not comply with the section cited above in which adult assistant, Nayeli Aparicio Perez, is not fingerprint cleared which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/12/2022
	Plan of Correction
1 2 3 4	Licensee will schedule an appointment for Nayeli Aparicio Perez to get fingerprinted and will send proof of scheduling/completion to the San Jose Regional Office by close of business on October 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: 10/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022

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: LOPEZ, MARIA LOURDES	FACILITY NUMBER: 274414462
	VISIT DATE: 10/11/2022

NARRATIVE

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Continuation of report dated 10/11/2022 pg. 2/3

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.

LPA took a picture of a current roster of the children. LPA observed a fire and disaster drill log that was last conducted on 06/22/22. LPA reviewed 13 children’s files and observed all required documentation was in compliance. 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.

Type A 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.

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Susy Cervantes	TELEPHONE: (408) 598-9403
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022

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: LOPEZ, MARIA LOURDES	FACILITY NUMBER: 274414462
	VISIT DATE: 10/11/2022

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Continuation of report dated 10/11/2022 pg. 3/3

LPA Susy Cervantes informed licensee, Maria Lourdes Lopez, that this report dated 10/11/2022 documents one Type A citation 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.

Also, LPA Susy Cervantes informed the licensee, Maria Lourdes Lopez, to provide a copy of this licensing report dated 10/11/2022 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.

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. 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: 10/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022

LIC809 (FAS) - (06/04)

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