430751096-9-19-2019-07-CC-AALZ-BG6PEQ-20190919111532

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 430751096
Report Date: 09/19/2019
Date Signed: 09/19/2019 11:15:39 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:	CASEY, XUAN & PATRICK		FACILITY NUMBER:	430751096
ADMINISTRATOR:	CASEY, XUAN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 629-4315
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY:	14	CENSUS: 2	DATE:	09/19/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	09:16 AM
MET WITH:	Casey, Xuan		TIME COMPLETED:	11:35 AM

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	Licensing Program Analyst (LPA) Almaraz, Araceli conducted an annual random visit. LPA met with Licensee, Casey, Xuan and explained the nature of today's visit. Present during the visit was Licensee Casey . There were a total of two children present, one infant and one preschooler. The day-care is open 7 AM to 6 PM, Monday through Friday. There is one adult residing in the home; Licensee Casey. Licensee states there is an assistant that comes to assist in the afternoons, Assistant Le, Tam. LPA Almaraz reviewed two children's files and observed current and updated immunization records and the Family Child Care Home Notification of Parents' Rights forms (LIC 995A) in each file. LPA Almaraz observed a current roster. Licensee Casey has record of MMR & Tdap vaccinations as well for the flu vaccine. Licensee Casey has current CPR and First Aid which expires on 04/14/2020. Licensee Casey has not completed Mandated Reporter Training, Licensee Casey is waiting for Vietnamese edition and understands training is to be completed every two years once the initial class is taken. LPA Almaraz referred Licensee Casey to the Mandated Reporter Training website at *www.mandatedreporterca.com* LPA Almaraz observed a working smoke/carbon monoxide detector and 3A40BC fire extinguisher. LPA Almaraz observed a current fire disaster drill and earthquake drill last log 08/21/2019. LPA Almaraz did not observe any heaters in the home. LPA Almaraz observed a barricaded fire place. Report Continued on Page 2*****

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Araceli Almaraz	TELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2019

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: CASEY, XUAN & PATRICK	FACILITY NUMBER: 430751096
	VISIT DATE: 09/19/2019

NARRATIVE

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LPA Almaraz reminded Licensee Casey of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who come in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12-month period.

Website for provider resources: http://www.cdss.ca.gov/inforesources/Community-Care/Self-Assessment-Guides-and-Key-Indicator-Tools/Quarterly-Updates

There are no deficiencies during today’s inspection.

LPA Almaraz conducted an exit interview with Licensee Casey and advised licensee Casey of the pending Department regulation update re: safe sleep for infant children. LPA Almaraz referred Licensee Casey to the Department website: www.ccld.ca.gov for additional information. LPA Almaraz discussed the requirements of AB633 to Licensee Casey, Licensee Casey understands these requirements.

NOTICE OF SITE VISIT WAS ISSUED, AND MUST BE POSTED FOR 30 CONSECUTIVE DAYS.

Final Page of Report Continued from Page 3*****

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Araceli Almaraz	TELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2019

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: CASEY, XUAN & PATRICK	FACILITY NUMBER: 430751096
	VISIT DATE: 09/19/2019

NARRATIVE

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LPA Almaraz observed that there are no bodies of water inside or outside the home. LPA Almaraz inspected the indoor areas of the home today. Off limit areas in the home are as follows: One master bedroom/bathroom, two bedrooms, one bathroom and the garage This area is made inaccessible by a gate. Licensee Casey states the living room is used on occasionally for reading time with supervision. Medication, cleaning products and similar items are stored inaccessible to children. Poisons must be locked. Licensee Casey states that there are no weapons in the home. Licensee Casey has no pets, there was a visiting pet present during the inspection. Licensee Casey states that the pet is daughters. Licensee Casey has no day care insurance.

LPA Almaraz inspected the outdoor area of the home today. Off limit areas outside the home are as follows: The back yard, which is made inaccessible by gated windows. LPA Almaraz observed three locked sheds in the back yard. The front yard is safety compliant and backyard is fully fenced.

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

Supervision of the children was discussed; Licensee Casey understands a cleared adult must be present in the home during day care hours. Licensee Casey understands that the children must be supervised at all times. Licensee Casey understands the capacity options and ratio requirements. Licensee Casey understands not to leave children in the car unattended. Licensee Casey states that there is no transporting of children currently.
Report Continued on Page 3*****

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Araceli Almaraz	TELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2019

LIC809 (FAS) - (06/04)

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