434402379-2-24-2022-07-CC-PHEZ-CBXTPC-20220224135407

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434402379
Report Date: 02/24/2022
Date Signed: 02/24/2022 02:15:31 PM

Document Has Been Signed on 02/24/2022 02:15 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:	GORDON, PAMELA		FACILITY NUMBER:	434402379
ADMINISTRATOR:	GORDON, PAMELA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 257-5425
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95129
CAPACITY:	14	CENSUS:	DATE:	02/24/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Pamela Gordon		TIME COMPLETED:	02:03 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) Pete Hernandez conducted an unannounced annual random inspection at the home today. LPA met with Pamela Gordon, Licensee, and explained the nature of today's visit to her. Also present today was licensee's assistant Amanda Mikaelsson. There were 12 day care children present at the time of LPA arrival: 3 Infants, 6 school age children, and 3 preschoolers. Hours are Monday - Friday from 7:00AM to 6:00 PM. The Licensee lives in the home by yourself. LPA toured the indoor or and outdoor areas of the home. Fire drills are conducted every 6 months and logged: last entry was 1/3/22. The Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children. The home is orderly, and safe for the day care children. Off limit areas in the home are the hall way bathroom, and the right hand side yard. LPA observed a fully charged 2A10BC fire extinguisher. There are working smoke & carbon monoxide detectors in the home. LPA observed a fenced backyard. The Licensee states that she does not have any weapons in the home. All detergents, cleaning compounds, other similar items and poisons are inaccessible to children. LPA reviewed the files of 12 enrolled children, all the files have all of the required documentation and immunization's. REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #2 - REPORT DATED 2/24/22:

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Pietro Hernandez	TELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022

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: GORDON, PAMELA	FACILITY NUMBER: 434402379
	VISIT DATE: 02/24/2022

NARRATIVE

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Incidental Medical Services (IMS) policy was discussed. When any IMS is provided, an updated Plan of Operation that includes 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

A review of staff records today indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPA also reminded Licensee of the applicable civil penalties for those adults who have not received fingerprint clearances, 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

Supervision of children was discussed with the Licensee. Licensee understands that she must be present in the home at least 80 percent of the hours the day care is in operation and ensure that the children are supervised at all times. The Licensee understands her capacity options. The Licensee states that she does transport children and understands that children cannot be left in parked vehicles unattended at any time. Licensee understands that children's personal rights should not be violated; including no corporal punishment. Isolation of sick child, requirements for reporting suspected child abuse, unusual incidents/injuries, heat-related illnesses, and requirements for assistant/substitute were also discussed.

LPA informed Licensee that Licensing forms and Title 22 regulations, can be obtained through the internet at www.ccld.ca.gov
LPA discussed the Individual Infant Sleeping Plan LIC9227 with Licensee.
REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #3 - REPORT DATED 02/24/2022

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Pietro Hernandez	TELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022

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: GORDON, PAMELA	FACILITY NUMBER: 434402379
	VISIT DATE: 02/24/2022

NARRATIVE

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Licensee has a current CPR and First Aid certificate that expires on 3/1/22, Her assistant Amanda Mikaelsson's expires 7/1/22.
Website for resource information: http://www.cdss.ca.gov/inforesources/Community-Care/Self-Assessment-Guides-and-Key-Indicator-Tools/Quarterly-Updates

Licensee and assistant do have a current Mandated Reporter Certificates. LPA discussed Senate Bill 792, Assembly Bill (AB) 1207 (Mandated Child Abuse Reporting Training) which is required training that began on January 1, 2018 and requires renewal every two years, AB 633 was discussed with applicant Licensing forms, Title 22 regulations, can be obtained through the internet at www.ccld.ca.gov. Mandated Reported Training can be accessed at www.mandatedreporterca.com.

LPA also provided the e-mail address for the advocates in order to be added to the quarterly newsletter mailing list, childcareadvocatesprogram@dss.ca.gov

Type A language: Upon the issuance of Type A citations, a copy of the Facility Evaluation Report LIC809 has to be posted on the wall and a copy to be given to all parents of currently and newly enrolled children for next 12 months. In addition, copy of LIC9224 Statement Acknowledging Receipt of Licensing Reports need to be signed and kept in child files.

A deficiency is NOT being cited based on the LPA observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22, An exit interview was conducted with the licensee. A copy of this report and appeals rights were discussed and left with the Licensee, Pamela Gordon, whose signature on this form confirm receipt of these documents.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Pietro Hernandez	TELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022

LIC809 (FAS) - (06/04)

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