434403105-9-27-2023-07-CC-JBOT-CW3V5V-20230927160835

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434403105
Report Date: 09/27/2023
Date Signed: 09/27/2023 04:08:46 PM

Document Has Been Signed on 09/27/2023 04:08 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	VANDIVIER, ANNA		FACILITY NUMBER:	434403105
ADMINISTRATOR:	VANDIVIER, ANNA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 266-6141
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95118
CAPACITY:	14	CENSUS: 9	DATE:	09/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Anna Vandivier		TIME COMPLETED:	04:20 PM

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Licensing Program Analyst (LPA) Jessica Bongardt and Mel Matos met with Anna Vandivier, Licensee, for an unannounced Required – 1 year annual inspection. LPAs were granted access to the home by the Licensee. LPAs also observed nine day care children (3 Infants and 6 preschool), Licensee's spouse, Michael Vandivier, and Maria Leon, adult assistant, in the home during today's inspection. 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. Days and hours of operation are Monday thru Friday 7:00AM to 5:30PM. The adults residing in the home are: Licensee and her husband, Michael Vandivier.

LPAs reviewed a current Child Care Facility Roster and Fire/Disaster drill log during today's inspection. The last fire/disaster drill was completed on 07/14/2023. Licensee states that she does not have liability insurance for the day care and issues the Affidavit Regarding Liability Insurance for Family Child Care Home (LIC 282) to all enrolled families. Licensee and her adult assistant has current CPR and First Aid certifications (exp:02/05/2024). Licensee and her adult assistant has the required vaccines (MMR, Tdap, & flu) and is current with her Mandated Reporter Training for Child Care Workers. LPAs reviewed nine children's files and the files were complete with the required forms. LPAs reviewed two staff files (Licensee & adult assistant) and the files were complete with the required forms. Licensee states that a child will be isolated in the infant care area if necessary due to illness or communicable disease.

LPAs toured the indoor and outdoor areas of the home during today's inspection. Licensee has a working telephone in the home. The home is clean, orderly, (including heating/air conditioning/ventilation), and safe for the day care children. There are safe & age appropriate toys, play equipment, and materials for the children in the home. There are no stairs inside the home. LPAs did not observe any wall heater units inside the home. LPAs observed an electric decorative fireplace, located near the front entrance to the home, which is not in use per the Licensee. Off limit areas inside the home: Bedroom 1 & 2, Master Bedroom, Master Bathroom, Kitchen, Dining Room, Living Room, Family Room, Laundry Room, and Office. Off limit area outside the home: left side portion of backyard, and locked storage shed.

LPA observed a fully charged 3A40BC fire extinguisher, working smoke/carbon monoxide detectors, and fenced backyard. The Licensee states that she does not have any weapons in the home. Licensee has one dog that is vaccinated. Licensee was reminded that food and water for the dog needs to be kept out of reach for the day care children. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children. Any poisons are locked in the storage shed in the backyard.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Jessica Bongardt	TELEPHONE: 408-834-2558
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: VANDIVIER, ANNA	FACILITY NUMBER: 434403105
	VISIT DATE: 09/27/2023

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Licensee states that she does not administer any medications to the day care children. Licensee states that she does provides meals for the preschool children: Breakfast, Lunch, and Snacks. Licensee understands that any food brought from home shall be labeled with each child's name and properly stored. Licensee has a first aid kit in the home which includes a touch less thermometer. Licensee states that nobody smokes and she understands that smoking is prohibited in the home.

Supervision of children was discussed with the Licensee and he/she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. Licensee understands her capacity/ratio options and she understands that she cannot have more than 14 children present in the home without two qualified adults present. Licensee states that she does not transport any day care children. 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.

Anna Vandivier, Licensee, was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.

LPAs discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. 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.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Jessica Bongardt	TELEPHONE: 408-834-2558
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: VANDIVIER, ANNA	FACILITY NUMBER: 434403105
	VISIT DATE: 09/27/2023

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Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Exit interview conducted and report was reviewed with the Licensee, Anna Vandivier. No deficiencies issued during today's inspection.

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

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Jessica Bongardt	TELEPHONE: 408-834-2558
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

LIC809 (FAS) - (06/04)

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