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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434403680
Report Date: 08/07/2024
Date Signed: 08/07/2024 05:10:47 PM


Document Has Been Signed on 08/07/2024 05:10 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:ROSALES, CARMENFACILITY NUMBER:
434403680
ADMINISTRATOR:ROSALES, CARMENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 239-0612
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY:14CENSUS: 5DATE:
08/07/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Carmen RosalesTIME COMPLETED:
05:25 PM
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Licensing Program Analyst (LPA) Martha Jimenez-Villanueva met with Carmen Rosales for an unannounced Inspection. LPA explained the nature of today’s inspection to her. Present during today's visit were Licensee, Assistant and five children in care: three infants, one toddler, one preschooler. Adults living in the home are Licensee, her husband, her son, and her daughter in law. No children at home. Days and hours of operation are Monday through Friday from 6:00 AM to 6:00 PM.

A review of staff records on 08/07/2024 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. 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 inspected indoor and outdoor areas of the home. LPA observed facility is insured with DC Insurance Services Inc and expired on 04/19/2025. LPA observed, no wall heater, and no bodies of water. LPA observed one story home with no stairs. LPA did not observed fireplace at home. LPA observed a central heating/air conditioning and ventilation for safety and comfort of the children. Licensee stated there are no weapons and no pets. LPA observed a full fire extinguisher 2A10BC that was serviced on 08/06/2024. Carbon Monoxide detector and smoke detector were operable. Sharp objects, medicines, poisons, and cleaning supplies are inaccessible to the children and stored in a top cabinet in the kitchen, in the laundry area. LPA observed the backyard is fenced. A fire clearance granted from the San Jose Fire Department was received on June 20, 2024. Off limit areas indoor: master bedroom/bath, two bedrooms and hallway closet and the attached garage. The day area is the living room, and dinner room, the kitchen and one room located in the end of the hallway to the right. Off limits outdoor: left side of the home that is fenced off to children and locked storage.
Report Continues in 809-C page 2.
SUPERVISOR'S NAME: Belinda DevallTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Martha Jimenez-VillanuevaTELEPHONE: 408-324-2148
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024
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 4


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: ROSALES, CARMEN
FACILITY NUMBER: 434403680
VISIT DATE: 08/07/2024
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Report 08/07/2024 continues from page 1.

LPA took a picture of a current roster of the children and a fire and disaster drill log which was last completed on 07/18/2024. LPA reviewed five children's files and observed all required documentation, including LIC 9227 and sleep log are completed and current, exempting Child (1) missing LIC 9227. Licensee has insurance with DS Insurance Services expired on 4/19/2025. . LPA observed that the Licensee and her assistants (2) have Mandated Reporter training, training was completed on 11/06/2023, 06/12/2023 and 07/16/2024 respectively. Licensee and her assistants have Pediatric CPR/1st Aid expiring 07/13/2025, 04/15/2025 and 07/13/2026 respectively. Needed documentation for SB 792 which requires immunization against Pertussis, Measles, and Influenza as well as TB testing is on file for licensee and assistants.

Supervision of children was discussed with licensees, and they understand that they must be present in the home during day care hours and ensure that the children are supervised at all times. Licensee understand their capacity options and they understand that they cannot have more than 14 children in the home at any time. Licensees understand in absence of a helper the capacity of their license is reduced in capacity and ratio to a small Family Child Care Home license, maximum 8 children. Licensee stated do not transport children, LPA reminded Licensee that children are never to be left in parked vehicles and must use appropriate car seats according to the child's age/weight/size.



LPA 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. 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.

Report Continues in 809-C page 3.
SUPERVISOR'S NAME: Belinda DevallTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Martha Jimenez-VillanuevaTELEPHONE: 408-324-2148
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: ROSALES, CARMEN
FACILITY NUMBER: 434403680
VISIT DATE: 08/07/2024
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Report 08/07/2024 continues from page 2.

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/.

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

Licensee were 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.

During the exit interview, the LICENSEE, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.



Exit interview conducted and report was reviewed with the Licensee Carmen Rosales in Spanish.

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

Failure to comply with posting requirements shall result in an immediate civil penalty of $100

SUPERVISOR'S NAME: Belinda DevallTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Martha Jimenez-VillanuevaTELEPHONE: 408-324-2148
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024
LIC809 (FAS) - (06/04)
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