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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434401958
Report Date: 08/22/2022
Date Signed: 08/22/2022 05:44:21 PM


Document Has Been Signed on 08/22/2022 05:44 PM - It Cannot Be Edited

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:ARGUELLES, BERTHAFACILITY NUMBER:
434401958
ADMINISTRATOR:ARGUELLES, BERTHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 243-8267
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY:14CENSUS: 8DATE:
08/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Bertha ArguellesTIME COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs), Teodoro Trujillo and Fermin Campos-Jaramillo, met with Licensee, Bertha Arguelles, for an unannounced Required - 1 Year Inspection. LPAs were granted access to the home by the Licensee and toured both indoor and outdoor areas during the inspection. Also present in the home was a assistant Leticia, 4 infant and 4 preschool children. LPAs observed all required posted materials were not in place, licensee posted them back. Days and hours of operation for the facility are Monday – Friday 7:30 AM- 5:45 PM. Licensee is serving children ages 0 years to 18 years old. There are no active waivers or exceptions for this facility. Licensee states that she is the only adult residing at this address.
A review of staff records on 8/17/22 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.
Licensee Bertha Arguelles 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.

LPAs reviewed and obtained copy of facility roster (LIC9040). Fire/disaster drill was conducted on June 15, 2022. LPAs observed a fully charged 3A40BC fire extinguisher, screened fireplace, and functioning smoke and carbon monoxide detectors. Licensee states that she currently has one child in care who require Incidental Medical Services and does administer medication at this time. Licensee states that there are no weapons or firearms in the home.


Continuation on next pages
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2022
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: ARGUELLES, BERTHA
FACILITY NUMBER: 434401958
VISIT DATE: 08/22/2022
NARRATIVE
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Indoor licensed areas of the facility were inspected by LPAs today and observed to be clean, orderly, and safe for the day care children. LPAs observed a barricaded wall heater. Off-limits areas in the home include indoor: all of second floor, first floor kitchen, one bedroom, one office, garage and laundry area. . LPAs observed sufficient age-appropriate materials, toys, and play equipment in the facility. Furniture, such as tables, chairs, and shelves, are in good condition and safe for children. The floors were clean and free of tripping hazards. Drinking water is readily available for children in the facility via filtered water and individual water bottles from home. The bathroom in the home is clean, sanitary, and operable. The Licensee has a working telephone in the facility.

The outdoor licensed areas of the home was inspected and observed to be fenced in. Off limit areas outside the home include: right side fenced off back area, storage shed. There were no bodies of water observed.

Eight (8) children’s files were reviewed during todays inspection for the following records: Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), Affidavit Regarding Liability Insurance (LIC 282), and Immunization Records (PM286). Two Technical Violations were issued.

Licensee's Mandated Reporter Training for Child Care Providers was expired on January 23, 2021, Assistants Leticia is current, completed March 27, 2021. Mandated Reported Training can be accessed at www.mandatedreporterca.com. Licensee's CPR/First-Aid expires on February 27, 2023 and assistant CPR/First-Aid expires on February 19, 2024. LPAs reminded Licensee that Mandated Reporter Training must be renewed by all staff every 2 years.

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SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022
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: ARGUELLES, BERTHA
FACILITY NUMBER: 434401958
VISIT DATE: 08/22/2022
NARRATIVE
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Supervision of children was discussed with the Licensee and she understands that children are supervised at all times. The Licensee states that she does not transport any day care children. LPAs reminded Licensee that children should not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping. LPAs reminded licensee about the capacity options of her license.

LPAs also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

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

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Exit interview conducted and report was reviewed with the licensee Bertha Arguelles

Three type A deficiencies were cited today.

Five type B deficiencies were cited today.

A notice of site visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/22/2022 05:44 PM - It Cannot Be Edited

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: ARGUELLES, BERTHA
FACILITY NUMBER: 434401958

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102425(b)(1)(A)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects. (1) Pacifiers shall be allowed in the crib or play yard if the following provisions are in place: (A) There shall not be anything attached to the pacifier.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, LPAs observed two sleeping infants,(EW and JO) with pacifiers with cord attached which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2022
Plan of Correction
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Licensee immediately removed the cord, licensee will submit a written statement to LPA Trujillo, stating that she understands the safe sleep regulations and avoid that incident to happen in the future by the end of business day of 08/23/2022. AB633 requirements was explained to Licensee and she understood.
Type A
Section Cited
CCR
102425(f)
Infant Safe Sleep
An infant shall not be swaddled while in care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, LPAs observed a sleeping infant (JO) swaddled in crib, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2022
Plan of Correction
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Licensee assistant immediately un-swaddled sleeping infant, licensee will submit a written statement to LPA Trujillo, stating that she understands the safe sleep regulations and avoid that incident to happen in the future by the end of business day of 08/23/2022. AB633 requirements was explained to Licensee and she understood.

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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/22/2022 05:44 PM - It Cannot Be Edited

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: ARGUELLES, BERTHA
FACILITY NUMBER: 434401958

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102425(j)(5)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: If the infant is sleeping in a separate room from where the provider is stationed, the door to the room the infant is sleeping in shall remain open at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, LPAs observed a closed door to a room with sleeping infants, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2022
Plan of Correction
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Licensee immediately opened the door, licensee will submit a written statement to LPA Trujillo, stating that she understands the safe sleeping regulations and avoid that incident to happen in the future by the end of business day of 08/23/2022. AB633 requirements was explained to Licensee and she understood.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2022
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: ARGUELLES, BERTHA
FACILITY NUMBER: 434401958

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(3)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (3) Where children are less than five years old are in care, stairs shall be fenced or barricaded.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, LPAs observed a broken stair barricade that was no put in place, was leaning against the bottom stair wall, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/06/2022
Plan of Correction
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Licensee will acquire a replacement working stair barricade and will submit picture of installed barricade by the end of business of 09/06/2022.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above, LPA observed that licensee last completed Mandated Reporter Training on 01/23/2019, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/06/2022
Plan of Correction
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Licensee will renew a Mandated Reporter Training and submit proof of completion to Licensing by end of business day 09/06/2022.

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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/22/2022 05:44 PM - It Cannot Be Edited

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: ARGUELLES, BERTHA
FACILITY NUMBER: 434401958

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.3(a)(6)
Alterations to Existing Building or Grounds
(a) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following: (6) Any change from an area of the family child care home previously identified as "off limits" to an area where care and supervision will be provided to children in care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above , LPAs observed two infants sleeping in a former off limit room, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/06/2022
Plan of Correction
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Licensee will to complete a revised facility sketch by the end of business day of 09/06/2022.
Type B
Section Cited
CCR
102419(b)
Admission Procedures and Authorized Representatives Rights
(b) The licensee shall post the PUB 394 (8/02), Family Child Care Home Notification of Parents’ Rights Poster in a prominent, publicly accessible area in the family child care home at all times children are in care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, LPAs did not observe the requrired PUB 394 posted, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/22/2022
Plan of Correction
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Licensee immediately posted PUB 394 in a visible area within the home. Deficiency was cleared today.

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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/22/2022 05:44 PM - It Cannot Be Edited

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: ARGUELLES, BERTHA
FACILITY NUMBER: 434401958

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above, LPA reviewed assistant file and file did have proof of immunization for pertussis, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/06/2022
Plan of Correction
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Licensee will have her assistant Leticia obtain immunization for pertussis and provide proof to Licensing Department by end of business day 09/06/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2022
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: ARGUELLES, BERTHA
FACILITY NUMBER: 434401958
VISIT DATE: 08/22/2022
NARRATIVE
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The following type A and B deficiencies were cited on the attached page (809-D). Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction (POC) Due Date may result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.

LPAs Teodoro Trujillo and Fermin Campos-Jaramillo informed licensee Bertha Arguelles that this report dated 08/22/2022 document(s) 3 Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPAs Teodoro Trujillo and Fermin Campos-Jaramillo informed the licensee Bertha Arguelles to provide a copy of this licensing report dated 08/22/2022 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

A notice of site visit was given and must remain posted for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022
LIC809 (FAS) - (06/04)
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