<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434403022
Report Date: 02/04/2020
Date Signed: 02/04/2020 11:43:22 AM

COMPREHENSIVE INSPECTION
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:FERNANDEZ, MARISSAFACILITY NUMBER:
434403022
ADMINISTRATOR:FERNANDEZ, MARISSAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
4082169154
CITY:SAN JOSESTATE: CAZIP CODE:
95116
CAPACITY:14CENSUS: 2DATE:
02/04/2020
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Fernandez Marissa TIME COMPLETED:
11:55 AM
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
On February 4, 2020 Licensing Program Analysts (LPA) Stephanie Collins conducted an annual inspection of Family Community Care Home of licensee Fernandez Marissa . LPA met with Licensee and explained the purpose of today's inspection. Present in the home were #2 children of whom 1 was infant age, and Licensee’s Tristanjam Fernandez . Days and hours of operation are Monday through Friday from 6:30 AM –6:30 PM. Licensee understands the capacity options and understands that the maximum capacity is 14 children.
There are Three (3) adults residing in the home; Licensee and Licensee’s Husband (Robert Fernandez) with their son Tristanjam Fernandez . A review of staff records on (02/03/2020 shows that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPA 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.

Licensee's Pediatric CPR and First Aid expires on 11/2020. LPA reviewed Licensee’s file. LPA observed Licensee was unable to provide proof of immunity against (MMR) Measles or (Tdap) Pertussis. Licensee was unable to show proof of AB1207 Mandated Reporter Training Certificate.

LPA reviewed (#2 ) children's files. Records review include Parents' Rights, immunization, Emergency Contact Information, and Consent for Emergency Medical Treatment form. Family Child Care Home Notification of Parents' Rights forms (LIC 995A), Emergency Contact Information, and Consent for The form LIC 282 "Affidavit Regarding Liability Insurance" were kept in the children's file. LPA reviewed the roster of children in care and a copy was obtained.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Stephanie CollinsTELEPHONE: (408) 334-8555
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2020
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 5
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: FERNANDEZ, MARISSA
FACILITY NUMBER: 434403022
VISIT DATE: 02/04/2020
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
LPA inspected the indoor and outdoor areas of the home today. Smoke and Carbon monoxide detectors were tested and proved not to be functioning. LPA observed a fully charged 2A-10-B C fire extinguisher. Fire and disaster drills were last conducted and recorded on 12/17/2019 Licensee is aware that she must have at least one drill every 6 months . Off limits area in the home : All of the upstairs area. (Child safety gate at bottom of staircase to ensure inaccessibility of day-care children), Garage is also off limits . Marissa's states her husband has 1 firearms in a safe in the off-limit master bedroom and the ammunition is locked in a metal container in the garage. LPA observed a fully fenced back-yard which is off limits at this time due to re-organization. No bodies of water were observed
Medication, cleaning products and similar items that can pose a danger to children if readily accessible are stored inaccessible to children.
Licensee states that currently she is not providing Incidental Medical Services. 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. .
Licensee stated she does transport children. Licensee has a current and valid Driver License. Licensee understands that children cannot be left in parked vehicles unattended at any time, the motor vehicles used to transport children in care shall be maintained in safe operating conditions, and all vehicle occupants must be secured in an appropriate restraint system.
Beginning January 1, 2019 AB2370 requires licensed homes and centers to share information on the risks and effects of lead exposure with enrolling and re-enrolling families. LPA provided a copy of the “Lead Poisoning Facts Information Flyer” to the facility.

Safe sleep information was reviewed with Licensee.

LPA referred the Licensee to the Department website: www.ccld.ca.gov for additional information.

Regulatory violations were observed during the inspection visit. Therefore, citations were issued. Exit Interview was conducted, where this report, the citations, plan of corrections, and appeal rights were discussed and reviewed with Licensee. A copy of this report was given to Licensee.



A NOTICE OF SITE VISIT WAS ISSUED AND MUST BE POSTED FOR 30 CONSECUTIVE DAYS.


SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Stephanie CollinsTELEPHONE: (408) 334-8555
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2020
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: FERNANDEZ, MARISSA
FACILITY NUMBER: 434403022
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/25/2020
Section Cited

1
2
3
4
5
6
7
MANDATED REPORTER TRAINING. [...] a person who, on January 1, 2018, is a licensed child care provider [...] shall complete the mandated reporter training provided [...] and shall complete renewal mandated reporter training every two years [...].
This requirement is not met as evidenced by:
8
9
10
11
12
13
14
Per LPA's review of record, Licensee Marissa has not completed the required AB1207 Mandated Reporter Training. This poses a potential risk to children's health and safety of children in care.
8
9
10
11
12
13
14
Type B
02/05/2020
Section Cited

1
2
3
4
5
6
7
IMMUNIZATION. The child’s immunization shall be documented and maintained on file as long as the child is enrolled.
This requirement is not met as evidenced by:
Per LPA's review of files, Child 2 doesv not have immunization record on file during today's inspection. This poses a
8
9
10
11
12
13
14
potential risk to the health and safety of children in care.
8
9
10
11
12
13
14
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: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Stephanie CollinsTELEPHONE: (408) 334-8555
LICENSING EVALUATOR SIGNATURE:
DATE: 02/04/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2020
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: FERNANDEZ, MARISSA
FACILITY NUMBER: 434403022
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/25/2020
Section Cited

1
2
3
4
5
6
7
CARBON MONOXIDE DETECTORS REQUIRED. Every licensed child day care center shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall accoun
8
9
10
11
12
13
14
for the presence of these detectors during inspections.
LPA did not observed at least 1 carbon monoxide detector during today's inspection. When requested, staff was unable to provide LPA evidence of an installed carbon monoxide detector during today's inspection
8
9
10
11
12
13
14
Type B
02/25/2020
Section Cited

1
2
3
4
5
6
7
HEALTH & SAFETY CODE. Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. [...] The day care center shall maintain documentation of the required immunizations.
8
9
10
11
12
13
14
This requirement is not met as evidenced by: Per LPA's review of files, Licensee Fernandez Marissa does not have documented evidence of immunity against Measles and/or Pertussis available for review during the inspection. This poses a potential risk to
8
9
10
11
12
13
14
POC Due date 02/25/2020 Licesnee agreed to mail proof of immunity against Measles and Pertussis to CCL officeby POC Date.
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: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Stephanie CollinsTELEPHONE: (408) 334-8555
LICENSING EVALUATOR SIGNATURE:
DATE: 02/04/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2020
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: FERNANDEZ, MARISSA
FACILITY NUMBER: 434403022
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/25/2020
Section Cited

1
2
3
4
5
6
7
Childs Records. The licensee shall maintain, in each child’s record, a copy of the emergency information card required in Section 102417(g) (7) and Forms .LIC282, LIC9150,LIC627, LIC995A not found in childern file. This requirment was met as evidenced by:
8
9
10
11
12
13
14
Per LPA'S review of of file during inspection. C1 and C2 have incomplete records or no records. this Poses a potential risk to children's health and safety of children in care
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Stephanie CollinsTELEPHONE: (408) 334-8555
LICENSING EVALUATOR SIGNATURE:
DATE: 02/04/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2020
LIC809 (FAS) - (06/04)
Page: 5 of 5