434403446-5-18-2023-07-CC-AMOS-CRXT6B-20230518142653

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434403446
Report Date: 05/17/2023
Date Signed: 05/18/2023 02:26:58 PM

Document Has Been Signed on 05/18/2023 02:26 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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	AMBROCIO-GACAYAN, PATRICIA		FACILITY NUMBER:	434403446
ADMINISTRATOR:	PATRICIA AMBROCIO-GACAYAN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 251-4728
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95133
CAPACITY:	14	CENSUS: 3	DATE:	05/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:55 PM
MET WITH:	Patricia Ambrocio-Gacayan		TIME COMPLETED:	03:45 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	LPA Anna Morales conducted an unannounced Annual/Required Inspection. LPA met with Licensee Patricia Ambrocio-Gacayan. Present in the home were three infants( over twelve months) who were napping at time of this visit. Days and hours of operation are Monday - Friday from 7:30AM -5:30 PM. Last disaster drill was conducted on 4/20/2023. LPA observed a current Children's Roster. Adults over the age of 18 and residing in the home are the Licensee and her spouse. LPA toured the indoor and outdoor areas of the home during today's inspection. The Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children. The home is clean, orderly, and safe for the day care children. LPA did not observe any wall heaters inside the home. Off limits Garage, entire upstairs, deck and right side yard. There is a barricaded fire place in the living room. LPA observed a gate in front of the stairs. LPA observed a fully charged fire extinguisher, working smoke/carbon monoxide detectors and a fenced backyard. The children play on the left side of the backyard and there is a children's gate separating the left and right side. The Licensee states that she does not have any pets. Licensee stated that she has weapons stored and secured in an off limits area. Licensee stated that the ammunition is stored/separated from the weapon(s). There is a swimming pool in the backyard which is covered with a pool cover that supports the weight of an adult. Licensee stated that it is secured and can only be manually open with two poles. Licensee stated that there is an automatic pump device so rain water can't accumulate on top of the cover. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children. (page 1).

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Anna Morales	TELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: AMBROCIO-GACAYAN, PATRICIA	FACILITY NUMBER: 434403446
	VISIT DATE: 05/17/2023

NARRATIVE

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Licensee stated that she does not transport children, and does not provide Incidental Medical Services (IMS). Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. Licensee have an area where sick children can be isolated from the others until parent pick-up.

Licensee has a current Mandated Reporter Training (AB1207). It expires in 5/11/2024. LPA discussed Senate Bill 792, Assembly Bill (AB1207 Mandated Child Abuse Reporting Training) which is required training that began on January 1, 2018 and requires renewal every two years, AB 633 was discussed with applicant Licensing forms, Title 22 regulations, can be obtained through the internet at www.ccld.ca.gov. Mandated Reported Training can be accessed at www.mandatedreporterca.com.

Licensee's files were reviewed for the following records: Employee Rights (LIC9052), Criminal Record Statement (LIC508), Statement Acknowledging Requirement to report Child Abuse (LIC9108), and Immunization Record showing immunity to measles (MMR), pertussis (Tdap), and influenza (or statement declining influenza). Licensee has a current First Aid/CPR on file and it expires in 6/25/2024.

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 comes 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

LPA discussed the requirements of AB 633 with the Licensee and understands the AB 633 fact sheet/copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224). LPA discussed "zero tolerance" related regulations and advised that 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

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Anna Morales	TELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: AMBROCIO-GACAYAN, PATRICIA	FACILITY NUMBER: 434403446
	VISIT DATE: 05/17/2023

NARRATIVE

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Exit Interview was conducted with Licensee. No Deficiencies are being cited based on the LPA's observations, interviews conducted and records reviewed in accordance with the California Code of Regulations Title 22.

A NOTICE OF SITE VISIT WAS ISSUED AND LICENSEE WILL POST THIS FORM THIS FORM NEAR THE ENTRANCE OF THE HOME AND MUST REMAIN POSTED FOR 30 DAYS.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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) 566-5850
LICENSING EVALUATOR NAME: Anna Morales	TELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

LIC809 (FAS) - (06/04)

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