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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430755592
Report Date: 10/16/2019
Date Signed: 10/16/2019 10:29:05 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:COVARRUBIAS,IRMA & JUANFACILITY NUMBER:
430755592
ADMINISTRATOR:COVARRUBIAS,IRMA & JUANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 848-8005
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY:14CENSUS: 1DATE:
10/16/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:42 AM
MET WITH:Irma CovarrubiasTIME COMPLETED:
10:45 AM
NARRATIVE
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Licensing Program Analysts (LPA(s) Nancy Rodriguez and Samantha Yip conducted an Annual/Random Inspection. The purpose of today’s visit is to ensure the home is in compliance with Title 22 California Code of Regulations. LPA(s) met with Licensee Irma Covarrubias. Upon arrival, no daycare children were present at the time of inspection. Currently the only adults living in the home are the Licensee, her husband, sister and mother. .

The facility’s days and hours of operation are Monday through Friday from 5:00 am - 6:00 pm. The home maintains telephone service. LPA(s) observed required postings; including the Facility License (LIC 203), Emergency Disaster Plan (LIC 610) and Notification of Parents Rights (PUB 394). The facility is licensed for a maximum capacity of 14 children; Licensee stated that she understands capacity options. LPA(s) confirmed that Licensee completed Pediatric CPR & First Aid training with an expiration date of 1/20/2020. The Licensee has completed the Mandated Reporter Training.


An inspection of the physical plant inside and out resulted in the following observations:
INSIDE: The home was clean and orderly, with heating and ventilation for the safety and comfort of children in care. The observed children’s toys, play equipment, and furniture were in good condition. There were no baby walkers, swings, or bouncers observed at facility. A bathroom used by children was observed to be clean and in operating condition. The kitchen, food preparation area, and storage were observed to be clean, orderly and free from litter or rubbish.

Off Limit areas inside the home include: All bedrooms and garage.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Nancy RodriguezTELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2019
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
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,IRMA & JUAN
FACILITY NUMBER: 430755592
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/23/2019
Section Cited

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Each family child care home shall conduct fire drills and disaster drills at least once every six months. The licensee shall document the drills, including the date and time of each drill. This documentation shall be kept at the family child care home. This requirement was not met as evident by:
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Based on record review, Licensee failed to conduct a disaster drill with in the last 6 months. Last fire drill documented was 1/2019. This poses a potential risk to the health and safety to the children in care.
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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: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Nancy RodriguezTELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2019
LIC809 (FAS) - (06/04)
Page: 4 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: COVARRUBIAS,IRMA & JUAN
FACILITY NUMBER: 430755592
VISIT DATE: 10/16/2019
NARRATIVE
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A Notice of Site Visit has been issued and must remain posted for 30 consecutive days.

A Type B citation has been cited as a result of today's inspection. Exit interview conducted with Licensee Irma Covarrubias.



The licensee has been advised that Community Care Licensing forms and updates can be accessed at: http://www.cdss.ca.gov/inforesources/Child-Care-Licensing

LPA advised the Licensee of the new immunization requirement (pertussis, measles, and flu vaccines) for all Licensees and staff that work directly with the children. LPA observed staff immunization records.

LPA went over safe sleep for infants. www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf

www.mandatedreporterca.com

SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Nancy RodriguezTELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2019
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: COVARRUBIAS,IRMA & JUAN
FACILITY NUMBER: 430755592
VISIT DATE: 10/16/2019
NARRATIVE
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OUTSIDE: The backyard is fenced and is used for outdoor activity. There were no bodies of water observed. Poisons, detergents, cleaning compounds, medicines and other items which could pose a danger were stored in a place inaccessible to children. There were no weapons such as firearms stored on the premises and the facility does not provide transportation to the children in care. The licensee has current and up to date liability insurance for day care providers.

A fully charged fire extinguisher size 2A 10 BC was observed. Carbon Monoxide and Smoke Detectors were tested and proven to be functional. Fire/Disaster drill was last conducted on 1/2019. LPA reminded Licensee that fire/disaster drill need to be conducted every 6 months. Licensee stated that she will conducted fire/disaster drill today, 10/16/2019 and send proof to Licensing office. LPAs reviewed the roster of children in care and obtained a copy. Children’s files were reviewed, which included records of Identification and Emergency Information, Consent for Emergency Medical Treatment, Receipt for Parents' Rights Notice, and Immunization.

Licensee was given the current forms for childcare and 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 and the Healthy Beverage Act and AB633 requirements for type A violation.

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 will submit an updated plan of operation if in the future they provide any IMS services to a child in care.

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. LPAs provided a copy of the “Lead Poisoning Facts Information Flyer” to the facility.

SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Nancy RodriguezTELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2019
LIC809 (FAS) - (06/04)
Page: 2 of 4