434402611-6-17-2021-07-CC-MSMS-C43UBQ-20210617152644

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434402611
Report Date: 06/17/2021
Date Signed: 06/17/2021 03:26:54 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:	ANDERSON, COLLEEN		FACILITY NUMBER:	434402611
ADMINISTRATOR:	ANDERSON, COLLEEN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 505-4257
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95134
CAPACITY:	14	CENSUS: 10	DATE:	06/17/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Colleen Anderson		TIME COMPLETED:	04:00 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 Analysts (LPAs) Mel Matos and Ofelia Calivo met with Colleen Anderson, Licensee, for unannounced Required – 1 year annual inspection. LPAs were granted access to the home by the Licensee. LPAs also observed 11 children (8 preschool and 3 school age) and one adult assistant (Samantha Blanchard) in the home during today's inspection. The Licensee was operating within her capacity and ratio requirements. LPAs observed the required postings, including the facility license, near the front entrance to the home. The Licensee has a working telephone in the home. Days and hours of operation are Monday - Friday from 6:00 AM to 6:00 PM. The Licensee and her spouse are the adults residing in the home. Licensee's CPR and First Aid are current and expire on October 3, 2022. Licensee's adult assistant's CPR & First Aid certifications are current and expire on December 14, 2021. LPAs reviewed the Child Care Facility Roster and Fire/Disaster drill log during today's inspection. The last fire/disaster drill was completed on May 18, 2021. The Licensee and her adult assistant has the required vaccinations/opt out form (MMR, Tdap, & flu) and has current Mandated Reporter Training for Child Care Workers certificates on file. LPAs reviewed eleven children's files and observed current and updated Identification and Emergency Information (LIC 700) and the Family Child Care Home Notification of Parents' Rights forms (LIC 995A) in each file. The Licensee states that a child will be isolated in the living room area if the child shows signs of illness or communicable disease. Safe sleep update: LPAs discussed the new “Safe Sleep” regulations with the Licensee and provided a copy of the regulations, including the Individual Infant Sleeping Plan (LIC 9227) form to the Licensee. LPAs reminded the Licensee that infants up to 12 months of age must sleep on their backs, shall be supervised while they are sleeping, and documentation of sleep checks must be kept in each infant’s file. Infants shall not be swaddled. There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard. Cribs or play yards shall be free of loose articles and objects. REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #2 - REPORT DATED 06/17/2021)

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021

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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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: ANDERSON, COLLEEN	FACILITY NUMBER: 434402611
	VISIT DATE: 06/17/2021

NARRATIVE

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CONTINUATION OF PREVIOUS PAGE (PAGE #1 - REPORT DATED 06/17/2021):

LPAs toured the indoor and outdoor areas of the home during today's inspection. LPAs observed sufficient materials, toys, and play equipment for the day care children. The home is clean, orderly, and safe for the day care children. There are no stairs or fireplace units inside the home. Off limit areas inside the home: master bedroom, master bathroom, and bedrooms 1 & 2. Off limit areas outside the home: right side of the house which is the carport, dog yard, and two storage buildings located at the back section of the backyard.

LPAs observed a fully charged 3A40BC fire extinguisher, working smoke/carbon monoxide detectors, no bodies of water, and fenced backyard. The Licensee states that she has 2 dogs (Chihuahua and corgi) and one cage rabbit. Licensee stated she does not have any weapons in the home. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children. Any poisons are locked and inaccessible to the day care children. The Licensee states that she does not administer any medication to the day care children at this time.

A review of staff records on June 17, 2021 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPAs also reminded the 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 and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. The Licensee understands her capacity options and she understands that she cannot have more than 14 children in the home at any time without a fully qualified adult present. The Licensee states that does not transport any day care children. The Licensee understands that children shall not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.
REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #2 - REPORT DATED 06/17/2021):

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021

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: ANDERSON, COLLEEN	FACILITY NUMBER: 434402611
	VISIT DATE: 06/17/2021

NARRATIVE

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CONTINUATION OF PREVIOUS PAGE (PAGE #2 - REPORT DATED 06/17/2021):

LPAs discussed the requirements of AB 633 with the Licensee and provided her the AB 633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and the Licensee understands the requirements. LPAs also discussed "zero tolerance" related regulations with the Licensee and advised her of the assessment of an immediate $500 per day civil penalty for any violation of a "zero tolerance" related regulation. An ongoing civil penalty of $100 per day continues until the violation(s) is corrected.

Website for provider resources: http://www.cdss.ca.gov/inforesources/Community-Care/Self-Assessment-Guides-and-Key-Indicator-Tools/Quarterly-Updates

LPAs conducted an exit interview with the Licensee and the Licensee agreed to submit the following updated forms to LPA Matos by Friday July 2, 2021: 1) Application for a Family Child Care Home (LIC 279), 2) Emergency Disaster Plan (LIC 610A), and 3) Updated Indoor/Outdoor Facility Sketches (LIC 999).

No deficiencies issued during today's inspection.

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

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021

LIC809 (FAS) - (06/04)

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