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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430755592
Report Date: 09/28/2021
Date Signed: 09/28/2021 04:35:10 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,IRMA & JUANFACILITY NUMBER:
430755592
ADMINISTRATOR:COVARRUBIAS, IRMAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 848-8005
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY:14CENSUS: 3DATE:
09/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Jeannette CovarrubiasTIME COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Required- 1 Year inspection. LPA met with Jeannette Covarrubias, Licensee's daughter, and explained the reason for the inspection. Jeannette stated that Licensee is currently out and will not be returning onto later in the afternoon. Present during today's inspection were Jeannette and 3 children, whom 1 was infant age and Jeannette's child. All adults present have fingerprint clearance. Jeannette has a valid CPR/1st Aid, which expires on 01/2022.

There is board for required posting. LPA observed that COVID posters at the front door and inside the home.

LPA toured in the inside and outside of the home. The off-limit areas of the home are all the bedrooms, master bedroom, the two closet in the hallway, and the garage. The home was observed to be clean. All cleaning supplies, disinfectants were observed to be inaccessible to children. There is sufficient amount of toys for children. LPA provided Jeannette with safe sleep information and explained the safe sleep regulations to her. There is fully charged fire extinguisher and smoke detector. The last fire/disaster drill was conducted on 09/21/2021. Jeannette stated that there are no weapons, such as firearms, stored in the home.

The backyard is used and fenced. The off-limit areas are the left side of the yard and shed. All play equipment were observed to be age-appropriate. LPA observed that one of the plastic play structure was starting to crack, but was not sharp. LPA reminded Jeannette to check play structure for any cracks. There were no bodies of water observed during today's inspection.

2 children's files were reviewed during today's inspection. The records reviewed include but not limited to Emergency Contact Card. Assistant's file was not reviewed. Facility was informed that the Annual Inspection will continue and be completed at a later date.

As a result of this inspection, no deficiencies were cited. An exit interview was conducted where this report was discussed and provided to Jeannette Covarrubias, Licensee's daughter. A Notice of Site Visit has been issued and must be posted for 30 consecutive days.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
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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