434403177-9-8-2022-07-CC-EBEN-CJ3MA8-20220908092556

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434403177
Report Date: 08/19/2022
Date Signed: 09/08/2022 09:26:22 AM

Document Has Been Signed on 09/08/2022 09:26 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	CHAVEZ, NANCY		FACILITY NUMBER:	434403177
ADMINISTRATOR:	CHAVEZ, NANCY		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 224-8623
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95111
CAPACITY:	14	CENSUS: 2	DATE:	08/19/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Nancy Chavez		TIME COMPLETED:	04:00 PM

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Licensing Program Analyst (LPA) Elizabeth Berumen met with licensee Nancy Chavez for a required one year visit. LPA explained the nature of today’s inspection to her. Present were licensee, adult daughter (Jocelyn Chavez) and two school age day care children.
Days and hours of operation are Monday to Friday, 6:00am to 6:00pm. The adults that reside in the home are licensee, her husband, two adult sons, adult daughter, tenant (Jessie Gonzalez) and 12-year old daughter.

LPA inspected the indoor and outdoor areas of the home during today’s inspection. LPA observed that the home is clean and orderly, with heating and ventilation for safety and comfort of the children. LPA observed barricaded stairs in the home. LPA observed safe and sufficient materials, toys, and play equipment for the day care children. All sharp objects, detergents, cleaning compounds, medications, poisons, and other similar items inside the home are stored inaccessible to children. LPA observed a fully charged 2A10BC fire extinguisher. LPA observed a working combo smoke and carbon monoxide detector. Licensee states there are no weapons/firearms in the home. Off limit areas indoor: upstairs master bedroom/bath, two bedrooms, one bathroom and downstairs bedroom and attached garage. There are no bodies of water. Backyard is fenced. Off limits outdoor: right side of home that is fenced off to children and two locked storages on left side of the home. Licensee states she has two dog stays in the right side of the yard and are vaccinated. Licensee has eight Love birds.

LPA observed licensee and her daughter have current CPR and First Aid certification. Licensee’s expires 08/02/2023 and her daughter's 09/12/2022. Licensee and daughter have completed Mandated Reporter training.

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Elizabeth Berumen	TELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022

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: CHAVEZ, NANCY	FACILITY NUMBER: 434403177
	VISIT DATE: 08/19/2022

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LPA observed a current roster of the children and a fire and disaster drill log which was last completed on 08/16/2022. LPA reviewed two child's files and observed all forms are completed. LPA observed day care is insured with DCI.

Supervision of children was discussed with 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. Licensee understands her capacity options and she understands that she cannot have more than 14 children in the home at any time. Licensee understands if she transports children via vehicle, children cannot be left in parked vehicles unattended at any time.

Safe sleep update: LPA discussed the new “Safe Sleep” regulations with the Licensee including the Individual Infant Sleeping Plan (LIC 9227) form to the Licensee. LPA reminded the Licensee that infants up to 12 months of age must sleep on their backs, and all infants 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.

LPA discussed Zero Tolerance related regulations with licensee Nancy Chavez and was advised of the assessment of $500 immediate civil penalty and an ongoing $100 per day per violation continues until the violation(s) is corrected. LPA discussed the requirements of AB633 to licensee Nancy and provided her the AB633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and licensee understands the requirements. Upon receipt, licensee Nancy shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. Incidental Medical Services were discussed with the licensee. The licensee is not providing IMS (Incidental Medical Services) at this time. Licensee will submit an updated plan of operation if in the future they provide any IMS services to a child in care.
No deficiency was cited.

Notice of site visit was issued and must be posted for 30 days.

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Elizabeth Berumen	TELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022

LIC809 (FAS) - (06/04)

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