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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274415989
Report Date: 05/10/2022
Date Signed: 05/10/2022 11:25:06 AM


Document Has Been Signed on 05/10/2022 11:25 AM - 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:RAMIREZ PEREZ, CARLOSFACILITY NUMBER:
274415989
ADMINISTRATOR:CARLOS RAMIREZ PEREZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 214-4846
CITY:SALINASSTATE: CAZIP CODE:
93907
CAPACITY:14CENSUS: 3DATE:
05/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Carlos Ramirez PerezTIME COMPLETED:
11:40 AM
NARRATIVE
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On 05/10/2022 at 09:30 AM, Licensing Program Analyst (LPA) Susy Cervantes met with licensee, Carlos Ramirez Perez, for an annual inspection and explained the reason for the visit to them. Present during today's visit were licensee and assistant with 3 children: one preschool and two infants. Adults living in the home are licensee and occasionally his assistant. Days and hours of operation are Monday through Saturday 23 hours and 59 minutes per day.

A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 04/20/2022 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's assistant is fingerprint cleared, however they are not associated to the facility. 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 and no pets. LPA observed a fully charged 3A40BC fire extinguisher. 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. Backyard is fenced. Off limit areas: two bedrooms, one bathroom, garage, shed, right and left side yards.

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 assistant. 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 05/10/2022 pg. 1/2
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Susy CervantesTELEPHONE: (408) 598-9403
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2022
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 05/10/2022 11:25 AM - 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: RAMIREZ PEREZ, CARLOS
FACILITY NUMBER: 274415989

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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
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Based on record review, the licensee did not comply with the section cited above in which his assistant has been cleared, but their fingerprints have not been associated to the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2022
Plan of Correction
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Licensee will submit a transfer request form (LIC 9182), LIC 508 and a copy of a goverment issued ID for his assistant, Elisa, to the San Jose Regional Office (SJRO) by close of business on May 24, 2022
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in which Child 01 and 03 do not have a completed LIC 9227 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2022
Plan of Correction
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Licensee will provide LIC 9227 to parents to be completed and will submit completed form to SJRO by close of business on May 24, 2022

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: Susy CervantesTELEPHONE: (408) 598-9403
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 05/10/2022 11:25 AM - 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: RAMIREZ PEREZ, CARLOS
FACILITY NUMBER: 274415989

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2022

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 record review, the licensee did not comply with the section cited above in which 15 minute sleep logs for infants under 24 months were not completed for Child 01 and 03 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2022
Plan of Correction
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Licensee will check and document infants sleep every 15 mintues and will submit the sleep log to SJRO by close of business on May 24, 2022
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: Susy CervantesTELEPHONE: (408) 598-9403
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022
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: RAMIREZ PEREZ, CARLOS
FACILITY NUMBER: 274415989
VISIT DATE: 05/10/2022
NARRATIVE
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Continuation of report dated 05/10/2022 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 02/01/22. LPA reviewed 10 children’s files and observed all required documentation was in compliance. Infant individual sleeping plan (LIC 9227) for each infant under 12 months was provided and discussed and a 15 minute check sleep log for infants under 24 months was discussed. LPA observed that the Licensee and assistant have Mandated Reporter training, training was completed on 08/14/20 and 02/17/22. Licensee and assistant have Pediatric CPR/1st Aid expiring 10/10/23. Needed documentation for SB 792 which requires immunization against Pertussis, Measles, and Influenza as well as TB testing is on file for licensee, LPA reviewed assistants immunizations and they are in compliance.

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 B 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, Carlos Ramirez Perez. 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: Susy CervantesTELEPHONE: (408) 598-9403
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022
LIC809 (FAS) - (06/04)
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