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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274415563
Report Date: 06/07/2023
Date Signed: 06/07/2023 04:43:39 PM


Document Has Been Signed on 06/07/2023 04:43 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:MELGOZA DE ANAYA, ANAFACILITY NUMBER:
274415563
ADMINISTRATOR:MELGOZA DE ANAYA, ANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 970-6744
CITY:SALINASSTATE: CAZIP CODE:
93905
CAPACITY:14CENSUS: 14DATE:
06/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Ana Melgoza de AnayaTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analysts (LPA) Fermin Campos-Jaramillo conducted an unannounced annual required inspection to the home today. LPA met with licensee Ana Melgoza. Days and hours of operation are Monday to Saturday from 6:00 AM to 6:00 PM. The adults that reside in the home are the Licensee, her spouse Juan, and her tenant Isilda. There were fourteen children in care present today, included three infants, seven preschool age, and four school age. Licensee's minor children ages 15 and 13 reside in the home. Licensee's certifications for CPR and First Aid card is current and will expire on 1/21/24. Present today was licensee daughter and helper Evelyn.
LPA toured the indoor and outdoor areas of the home during today's inspection. Licensee has documented a fire drill during the last six months. Last fire drill was documented on 2/28/23. LPA obtained a copy of the Child Care Facility Roster during today's inspection and it is current. LPA reviewed five children's files and observed they include the parent's rights form and the immunization records form.
The Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the children in care. Off limit areas inside are: Two bedrooms, one bathroom, and the converted garage where Isilda resides. LPA observed there are not stairs in the home. LPA observed the home has fenced back yard. Licensee uses the back yard as playground for the children in care. Off limits out door areas are: The front yard, the left and right side yards, and a storage shed in the back yard. LPA observed there are not bodies of water.
LPA observed a fully charged 3A40BC fire extinguisher last time serviced on 2/22/23 and working smoke detectors. LPA observed the home has at least one working carbon monoxide detector. LPA observed there are not wall heaters. LPA observed the home has a blocked fireplace in the home, inaccessible to the children in care. The Licensee states that she does not have any weapons in the home. All detergents, cleaning compounds, medications, and other similar items are stored inaccessible to children.
Licensee has in file proof of immunization for pertussis and measles and an opt out statement for influenza vaccine according with the SB792.
*************Report dated 6/7/23 continues in page 2.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Fermin Campos-JaramilloTELEPHONE: 408-334-8557
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


Document Has Been Signed on 06/07/2023 04:43 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: MELGOZA DE ANAYA, ANA
FACILITY NUMBER: 274415563

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review the licensee did not comply with the section cited above in the count of three infants, Licensee stated is checking on infants at sleep every 15 minutes although she has not documented. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2023
Plan of Correction
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Licensee shall start documenting the checkings on sleeping infants every 15 minutes starting 6/08/23 and continue documenting until infants reach the age of 2 years old. Licensee will submit to licensing Program a copy of the log for the period 6/8/23 to 6/19/23 not later than 6/21/23 for 3 children (infants CH 1, CH2, CH3)
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: Fermin Campos-JaramilloTELEPHONE: 408-334-8557
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4


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: MELGOZA DE ANAYA, ANA
FACILITY NUMBER: 274415563
VISIT DATE: 06/07/2023
NARRATIVE
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Report dated 6/7/23 continues from page 1.

Supervision of children was discussed with the Licensee and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. The Licensee understands her capacity options and she understands that with a large license she can not have more than 14 children in the home at any time. Licensee understands that a helper is required to assist in the home whenever the number of children is greater than 8, and ratio must be observed. The Licensee states she understands that children cannot be left in parked vehicles unattended at any time. Licensee uses redirection and communication with children as a form of discipline.
Department website: www.ccld.ca.gov provided to Licensee.
LPA observed that the Licensee and her helper Evelyn have completed the required AB1207 "mandated reporter" training on 3/03/23 and same for helper Evelyn. Licensee understands the training is to be renewed every 2 years. Training website was provided: www.mandatedreporterca.com

A review of staff records on 6/06/23 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee Ana Melgoza 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 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.

Report dated 6/07/23 continues on page 3.

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Fermin Campos-JaramilloTELEPHONE: 408-334-8557
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: MELGOZA DE ANAYA, ANA
FACILITY NUMBER: 274415563
VISIT DATE: 06/07/2023
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Report dated 6/07/23 continuers from page 2.

Incidental Medical services (IMS) policy was discussed. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800)514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

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.

Exit interview conducted and report was reviewed with the licensee Ana Melgoza

One type B deficiency was cited today.

Failure to comply with the Plan Of Corrections (POC) by the due date on LIC809D shall result in an immediate civil penalty of $100 per day per each deficiency.

A notice of site visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Fermin Campos-JaramilloTELEPHONE: 408-334-8557
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4