430753754-5-2-2019-07-CC-SYIP-BBSTW6-20190502150502

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 430753754
Report Date: 05/02/2019
Date Signed: 05/02/2019 03:05:11 PM

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:	COVARRUBIAS, ROSA		FACILITY NUMBER:	430753754
ADMINISTRATOR:	COVARRUBIAS, ROSA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 778-2719
CITY:	MORGAN HILL	STATE: CA	ZIP CODE:	95037
CAPACITY:	14	CENSUS: 5	DATE:	05/02/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Rosa Covarrubias		TIME COMPLETED:	01:05 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	Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced annual random inspection. LPA met with Licensee Rosa Covarrubias and explained the reason for the visit. Present during the inspection were Licensee, Licensee's spouse, and 5 children. LPA observed License, Notification of Parent's Right, and Emergency Disaster Plan posted. Licensee carries daycare insurance. LPA toured the inside and outside of the home. The off-limit area of the home are all three bedrooms, the garage, and the two sheds in the backyard. There are no stairs in the home. There is a fireplace, which is barricaded to prevent access. All cleaning products are placed on top of the fridge and in the shed outside. LPA observed that the furniture, such as tables, chairs, and napping mats, were age appropriate. There is sufficient amount of toys for the children in care. LPA observed a fully charged fire extinguisher, functioning carbon monoxide detector, and smoke detector. The last fire drill was last conducted on 03/25/2019. Licensee stated that they are no weapons, such as firearms, in the home. The backyard is used for outdoor space and and is fenced. LPA observed that there are sufficient amount of play equipment for the children in care. LPA reminded Licensee to make sure the gate leading to the back is closed at all time and make sure there are no gaps in the fence, such as on the left side of the home. Licensee stated that she does not transport children, but understands that children should not be left alone and unattended in parked vehicles.

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2019

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: COVARRUBIAS, ROSA	FACILITY NUMBER: 430753754
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/02/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/09/2019 Section Cited CCR 102419(d)(1)	1 2 3 4 5 6 7	The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A, which acknowledges that the parent or authorized representative has received and read the LIC 995A. This requirement is not met as evident by:	1 2 3 4 5 6 7	By POC 05/09/2019, Licensee stated that she will submit a copy of signed LIC 995A to Licensing office.
	8 9 10 11 12 13 14	Based on record reviews, the Licensee failed to ensure all children have a signed LIC 995A in their file, which poses a potential risk to the health and safety to the children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Anthony Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2019

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: COVARRUBIAS, ROSA	FACILITY NUMBER: 430753754
	VISIT DATE: 05/02/2019

NARRATIVE

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LPA reviewed and obtained a copy of children' roster. 4 children's files were reviewed. The records reviewed included, but not limited to notification of parent's right. LPA observed that C-1, C-2, and C-3 did not have LIC 995: Notification of Parent's Right on in file. Licensee stated that she send a copy of completed notification of Parent's Right to Licensing office.

LPA reviewed Licensee's and her spouse's file. Licensee has a valid CPR/1st Aid, which expires on 01/02/2020. Licensee also has completed Mandated Reporter Training. Licensee stated that her spouse has not completed the Mandated Reporter Training because he is waiting for the Spanish version. LPA reminded Licensee that Mandated Reporter Training needs to be renewed every two years.

The adults living in the home are Licensee, her spouse, and her two adult children. All adults living in the home are fingerprinted cleared. 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. 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.

Licensee stated that she currently does not have any children in care who requires IMS services. Incidental Medical Services (IMS) policy was discussed. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. For IMS information, see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Home Section 102417. 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.

Licensee is encouraged to visit the Department’s website at www.cdss.ca.gov to access resources for Providers, Title 22 Regulations, Online Licensing Forms, Adoption of new Laws, etc.

In areas that were evaluated, a deficiency has been cited. An exit interview was conducted, where this report, the citation, plan of correction, and appeal rights were discussed with Licensee.

A NOTICE OF SITE VISIT WAS ISSUE AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS.

LPA was unable to print out and provide a copy of report dated 05/02/2019 due to consistency check.

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2019

LIC809 (FAS) - (06/04)

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