430755592-10-25-2021-07-CC-SYIP-C85S5G-20211025133418

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 430755592
Report Date: 10/19/2021
Date Signed: 10/25/2021 01:34:23 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 & JUAN		FACILITY NUMBER:	430755592
ADMINISTRATOR:	COVARRUBIAS, IRMA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 848-8005
CITY:	GILROY	STATE: CA	ZIP CODE:	95020
CAPACITY:	14	CENSUS: 3	DATE:	10/19/2021
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Irma Covarrubias		TIME COMPLETED:	12:35 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 Case Management- Annual Continuation inspection. LPA met with Licensee Irma Covarrubias and explained the reason for the inspection. Present during today's inspection were Licensee, Licensee's mother, Licensee's daughter, and 3 children, whom one was infant age and Licensee's grandson. All adults present have cleared fingerprints. During today's inspection, LPA reviewed her and her daughter, Jeanette's files. Licensee has a valid CPR/1st Aid, which expires on 01/02/2022. Licensee completed the Mandated Reporter training on 01/06/2020. LPA reminded Licensee that the Mandated Reporter training requires renewal every two years. Licensee does not have Mandated Reporter training or immunization records for measles and pertussis for her daughter, Jeanette. Licensee stated that she will have her daughter completed the Mandated Reporter training. Licensee stated that she will send a copy of her daughter's immunization records and Mandated Reporter training certificate to Licensing by 12/03/2021. LPA toured the inside and outside of the home. There is functioning smoke detector. Licensee has a Kiddie Combination Smoke and Carbon Monoxide detector, which did not make any sound when tested. Licensee stated that her husband just changed the battery. LPA informed her that there was a PIN sent out in regards to a recall on Kiddie Combination Smoke and Carbon Monoxide detectors. LPA provided Licensee with a copy of PIN 21-15. Licensee has a plug in carbon monoxide detector. LPA reminded Licensee that she needs to have a functioning carbon monoxide detector in the home. Licensee stated that there are no weapons, such as firearms, stored in the home. -------------------CONTINUES ON 809 DATED 10/19/2021 PAGE 2---------------------------------

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021

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 2

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: 10/19/2021

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
26
27
28
29
30
31
32

------------------CONTINUATION OF 809 DATED 10/19/2021 PAGE 1----------------------------
Licensee does not transport children at this time, but understands that children cannot be left alone and unattended in parked vehicles.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual- Regulation Interpretations and Procedures for Family Child Care 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 publications: Commonly Asked Questions about Child Care Center and the ADA, available at: http://www.ada.gov/childqanda.htm.

The adults living in the home are Licensee, her spouse, and her mother. All adults have cleared criminal record, child abuse index, and TB. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Licensee will submit the following to Licensing:
- an updated LIC 279 by 11/05/2021 to reflect the changes to the adults living in the home
- Mandated Reporter Training certificate for Jeanette
- immunization record for measles and pertussis for Jeanette

As a result of this inspection, a technical violation were cited. An exit interview was conducted with Licensee Irma Covarrubias, where this report and technical violation were discussed and provided. Appeals rights were provided to Licensee during today's inspection.

A Notice of Site Visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021

LIC809 (FAS) - (06/04)

Page: 2 of 2