434403105-3-21-2025-07-CC-JBER-DEXQ98-20250320115756

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434403105
Report Date: 03/20/2025
Date Signed: 03/21/2025 10:13:23 AM

Document Has Been Signed on 03/21/2025 10:13 AM - 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/ DIRECTOR:	VANDIVIER, ANNA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 266-6141
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95118
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS:	DATE:	03/20/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:45 AM
MET WITH:	Anna Vandivier		TIME VISIT/ INSPECTION COMPLETED:	12:20 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), Jennifer “Jen” Beehler, met with Anna Vandivier, Licensee for an unannounced Annual/Random Inspection. LPA was granted access to the home by the Licensee and toured both indoors and outdoors during the inspection. Upon arrival, there were 5 children (4 preschool/ 1 infant) and 2 staff (licensee/ helper) present, which is compliant with the home license capacity and ratio requirements. LPA observed all required postings near the entrance to the home. Hours of operation for the facility are Monday – Friday, 07:00AM-05:30PM. There are no active waivers. Licensee states that adults, over the age of 18, residing in the home are: herself and her spouse (Michael). All adults residing in the home have Criminal Background Check Clearance and signed Criminal Record Statements (LIC508). 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. LPA verified all adults present had criminal record clearance and were associated on the Guardian Roster. LPA reviewed facility roster (LIC9040) and fire/disaster drill log during todays inspection. The last fire/disaster drill was conducted on 02/12/2025, which is compliant with the six month requirement for homes. LPA observed a fully charged 3A40BC fire extinguisher last serviced on 12/07/2024 which is compliant with State Fire Marshal requirements. There was a fully functioning smoke detector and carbon monoxide detector present in the home. Licensee states that she does not currently have any children in care who require Incidental Medical Services. Continued on Page 2

Gladys Kuizon	TELEPHONE: (510) -56-5850
Jennifer Beehler	TELEPHONE: (408) 324-2148
	DATE: 03/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025

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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Document Has Been Signed on 03/21/2025 10:13 AM - 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: VANDIVIER, ANNA	FACILITY NUMBER: 434403105
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

102425(c)

Infant Safe Sleep

An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 3 out of 5 children's files which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/21/2025
	Plan of Correction
1 2 3 4	Licensee to complete LIC9227 and provide LPA with photographic proof of completion.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Gladys Kuizon	TELEPHONE: (510) -56-5850
Jennifer Beehler	TELEPHONE: (408) 324-2148
	DATE: 03/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025

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: 03/20/2025

NARRATIVE

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This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514- 0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

Indoor areas of the home were inspected by the LPA today and observed to be clean, orderly, and safe for the day care children. Off-limits areas of the home (indoors): All bedrooms, Dining Room, Living Room, Laundry room, Office, Kitchen and two additional Bathrooms. There are no open-faced heaters or fireplaces in the home. LPA observed sufficient age-appropriate materials, toys, and play equipment in the home. Furniture, such as tables, chairs, and shelves, are in good condition and safe for children. The Licensee states that there are no weapons or firearms in the home. LPA observed sharp objects in the kitchen in an upper cabinet and cleaning products in the off limits area of the laundry room. The bathroom used for the day-care is clean, sanitary, and operable. The Licensee has a working landline in the facility. Licensee mostly communicates with the parents through her cell phone. Licensee provides updates to parents throughout the day and meets each child at arrival and passes off each child to parents at pick up so any important updates can be discussed.

The backyard area of the home was inspected. LPA observed sufficient play equipment and supplies for the children that are in good condition and age-appropriate. Off-limit areas outside of home include: one side yard areas and front yard. No outdoor bodies of water were observed during todays inspection.

Licensee provides breakfast, lunch and an afternoon snack to day care children. LPA observed kitchen to be clean and preparation of food to be completed in a healthy and safe manner for the children. Licensee stated she provided proteins, grains, fruits and snacks in accordance with the recommended food pyramid for children's healthy eating. Licensee has water readily available to children through cups provided by the day care and filtered water from the kitchen sink.

Continued on Page 3

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (510) -56-5850
LICENSING EVALUATOR NAME: Jennifer Beehler	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025

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: 03/20/2025

NARRATIVE

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Infant Safe Sleep regulations (PIN 20-24-CCP) were discussed with the Licensee, including the Individual Infant Sleeping Plan (LIC9227). LPA reminded Licensee that infants up to 12 months of age should be placed on their back to sleep, that cribs should be free of all loose articles and hanging objects, and that infants should not be swaddled. Infants should be supervised while sleeping and documentation of sleep checks every 15 minutes should remain in the infant’s file. Documentation should include the time of the check, the infant’s physical condition, and initials of the staff member checking on the infant. Licensee can review additional information at the Licensing Safe Sleep webpage located at:https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep.

LPA 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.

5 children’s files were reviewed during todays inspection including: Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), Affidavit Regarding Liability Insurance (LIC282), Immunization Records (PM286), Individual Infant Sleep Plan (LIC9227) and sleep check documentation for all infants in care. 3 out of 5 children's files had incomplete LIC9227 or was missing the documentation. LPA reviewed the document with the provider to insure the form is filled out properly for all children enrolled under one year of age. Licensee confirmed understanding of the importance of the form, how to use it and how to properly update the form as the child in care develops.

2 staff files (Licensee/Helper) were reviewed. Employee Rights (LIC9052), Statement Acknowledging Requirement to report Child Abuse (LIC9108), Mandated Reporter Training Certificate, and Immunization Record showing immunity to measles (MMR), pertussis (Tdap), and influenza. There is at least one staff member present with current CPR/First-Aid that expires 02/05/2026. The Licensee has current Mandated Reporter Training that expires on 10/02/2025 and LPA reminded that training must be renewed by all staff every 2 years. LPA observed the helper's file missing LIC9052, LIC9108, LIC501 and flu vaccination. Licensee's file was missing an updated flu vaccination.

Continued on Page 4

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (510) -56-5850
LICENSING EVALUATOR NAME: Jennifer Beehler	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025

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: 03/20/2025

NARRATIVE

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Supervision of children was discussed with the Licensee and she understands that she must be home during day care hours and ensure that children are supervised at all times. The Licensee states that she does not transport any day care children. LPA 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.
During the inspection, the LPA confirmed that there are no Registered Sex Offenders living in the facility and completed the RSO profile in FAS.

LPA collected the following documents during today's inspection:

UPDATED LIC 279 with facility's new working hours

As a result of todays inspection, 1 Type B deficiency was cited, more information on the attached LIC809-D. Exit interview conducted with Licensee, Anna Vandivier, report reviewed and provided along with appeals rights.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (510) -56-5850
LICENSING EVALUATOR NAME: Jennifer Beehler	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025

LIC809 (FAS) - (06/04)

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