354405171-10-24-2019-07-CC-SCES-BH9KSK-20191024080938

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 354405171
Report Date: 10/23/2019
Date Signed: 10/24/2019 08:12:25 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:	MARTINEZ-SANDERS, MARY ELLEN		FACILITY NUMBER:	354405171
ADMINISTRATOR:	MARTINEZ-SANDERS, MARY ELL		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(831) 313-0914
CITY:	HOLLISTER	STATE: CA	ZIP CODE:	95023
CAPACITY:	14	CENSUS: 7	DATE:	10/23/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Mary Ellen Martinez-Sanders		TIME COMPLETED:	03:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	LPA and LPM Susy Cervantes and Mary Segura met with licensee Mary Ellen Martinez-Sanders for an annual/random inspection and explained the nature of today’s visit. Present were Licensee and her adult daughter Desiree, who is also her assistant, with 6 children of which 4 are infants. Adults living in the home are Licensee and her husband Robert. Days and hours of operation are Monday through Friday, 6:00 am to 6:00 pm. A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 10/21/19 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. LPA reminded Licensee of the applicable civil penalties for those adults who have not received fingerprint clearance, are not associated to the license and who come in contact with or provide care and supervision to the children. Licensee understands upon notice of the Department to remove an individual from the home, or to exclude an individual from the home, the licensee shall immediately remove the individual and prevent them from returning to the home or having contact with children in care. LPA toured the inside and outside of the home. LPA observed a blocked fireplace and no wall heaters. LPA observed no stairs. Off limits indoor: three bedrooms, 2 bathrooms, and one living room. There are no bodies of water. Licensee stated there are no firearms/weapons in the home. LPA observed two 3A40BC fire extinguisher that were last serviced on 2/21/19. Smoke detector and Carbon Monoxide detectors are operable. LPA observed sufficient materials, toys, and play equipment for the children in care as well as safe healthful, and comfortable accommodations, furnishings, and equipment. Telephone is in working order. Medicines, poisons and cleaning supplies are stored in garage and in a top kitchen cabinet and are inaccessible to the children. Backyard is fenced. There is a dog that is kept on the left side yard that is fenced. Licensee showed proof of dog vaccination. Off limits outdoor: left side yard that is fenced. Continues on report dated 10/23/2019

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Susy Cervantes	TELEPHONE: (408) 598-9403
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2019

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: MARTINEZ-SANDERS, MARY ELLEN	FACILITY NUMBER: 354405171
	VISIT DATE: 10/23/2019

NARRATIVE

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Continuation of report dated 10/23/2019

LPA reminded licensee that she can only have 14 children according to her license. Children were supervised during the visit and LPA went over substitute options. Licensee stated that she does not transports children, LPA reminded Licensee that children are never to be left in parked vehicles.

LPA received a copy of a current roster of the children and a fire and disaster drill log that was last conducted on 8/22/19. LPA reviewed 6 children’s files. Children’s immunization records are documented, maintained, and updated in form PM286. LPA observed Notification of Parents’ Rights is in each child’s file. LPA observed that the Licensee and assistant have completed Mandated Reporter training on 2/26/18. Licensee and Assistant have Pediatric CPR/1^st Aid expiring 9/25/21. LPA reviewed one employee file and observed licensee and assistant have all needed documentation for SB 792 which requires immunization against Pertussis, Measles, and Influenza (decline statement) as well as TB testing.

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 (Incidental Medical Services) at this time. Licensee has submit a plan of operation and it is in file.

Licensee was reminded that any authorized employee of the Department may enter and inspect any place providing personal care and services at any time, with or without advance notice. LPA discussed the immediate civil penalties for Zero Tolerance of $500 an AB633 requirements for type A violation. Beginning January 1, 2019 AB2370 requires licensed homes and centers to share information on the risks and effects of lead exposure with enrolling and re-enrolling families. LPA provided a copy of the “Lead Poisoning Facts Information Flyer” to the facility. Safe sleep was discussed with the Licensee and Guide to Safe Sleep information was provided to the licensee. Department website: http://ccld.ca.gov provided to Licensee.

An exit interview was conducted with Licensee. No deficiencies were cited during today's visit.

Notice of site visit must remain posted 30 days

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Susy Cervantes	TELEPHONE: (408) 598-9403
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2019

LIC809 (FAS) - (06/04)

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