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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274450234
Report Date: 07/28/2022
Date Signed: 07/28/2022 11:24:43 AM


Document Has Been Signed on 07/28/2022 11:24 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:FERNANDEZ, MARIAFACILITY NUMBER:
274450234
ADMINISTRATOR:MARIA FERNANDEZFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 223-7240
CITY:SOLEDADSTATE: CAZIP CODE:
93960
CAPACITY:14CENSUS: 5DATE:
07/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Maria FernandezTIME COMPLETED:
11:35 AM
NARRATIVE
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On 07/28/2022 at 9:45 AM, Licensing Program Analyst (LPA) Susy Cervantes met with licensee, Maria Fernandez, for an annual inspection and explained the reason for the visit to them. Present during today's visit were licensee and three of their daughters with 6 children: one school age, three preschool and two infants. Adults living in the home are licensee, their spouse and their son with two children ages 16 and 15. Days and hours of operation are Monday through Friday 5:00 AM to 5:00 PM.

A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 06/09/2022 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 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 no fireplace, no wall heater, no stairs, and no bodies of water. Licensee stated there are no weapons. Licensee stated they a dog and they are vaccinated. 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 top kitchen cabinet. Backyard is fenced. Off limit areas: four bedrooms, one bathroom, one extra room, laundry room, 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 an aid. 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 07/27/2022 pg. 1/2
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Susy CervantesTELEPHONE: (408) 598-9403
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2022
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 07/28/2022 11:24 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: FERNANDEZ, MARIA
FACILITY NUMBER: 274450234

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)(1)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. (1) This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home.

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 04 & 06 are missing PM 286 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/11/2022
Plan of Correction
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Licensee will ask parents to submit immunization records and licensee will transcribe them onto PM 286. Licensee will submit a copy of PM 286 for Child 04 & 06 to the San Jose Regional Office (SJRO) by close of business on August 11, 2022.
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 Child 04 & 06 are missing 15 minute sleep logs which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/11/2022
Plan of Correction
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Licensee will create a 15 minute sleep log and will document each infants under 24 month's sleep. Licensee will submit a completed (2-3 days) sleep log for Child 04 and 06 to SJRO by close of business on August 11, 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: 07/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2022
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: FERNANDEZ, MARIA
FACILITY NUMBER: 274450234
VISIT DATE: 07/28/2022
NARRATIVE
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Continuation of report dated 07/27/2022 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 06/03/22. LPA reviewed 6 children’s files and observed Child 04 and 06 are missing 15 minute sleep logs and Immunizations (PM 286). LPA observed that the Licensee has Mandated Reporter training, training was completed on 09/10/21. Licensee has Pediatric CPR/1st Aid expiring 04/2024. 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 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, Maria Fernandez. 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: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4