434403885-8-10-2022-07-CC-FCJO-CH6VW6-20220810164726

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434403885
Report Date: 08/10/2022
Date Signed: 08/10/2022 04:51:12 PM

Document Has Been Signed on 08/10/2022 04:51 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	VILLALOBOS, ROSA		FACILITY NUMBER:	434403885
ADMINISTRATOR:	VILLALOBOS, ROSA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 293-1511
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95126
CAPACITY:	14	CENSUS: 10	DATE:	08/10/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:25 PM
MET WITH:	Rosa Villalobos		TIME COMPLETED:	04:40 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 Analysts (LPA) Fermin Campos-Jaramillo met with Licensee, Rosa Villalobos, for an unannounced annual inspection. Licensee's helper Martha was also present and assisting with the children. LPA observed 10 day care children; including three infants, six preschool age, and one school age present during today's inspection. Days and hours of operation are Monday - Saturday from 6:00 AM to 11:00 PM. Licensee stated she is the only adult living in the home. Licensee's certifications for CPR and First Aid are current and will expire on 3/28/23 for both licensee and her helper. LPA toured the indoor and outdoor areas of the home during today's visit. LPA obtained a copy of the current children's roster. LPA reviewed the Fire/Disaster drill log during today's visit. The last fire drill was documented on 2/02/22. LPA reviewed 14 children files and they are complete. 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. LPA observed licensee has placed inaccessible to children all the cleaning compounds and medications. Off limit areas in the home: i bedroom and one bathroom. There are not stairs in the home. Off limit areas outside the home: Licensee has a detached unit in the back yard and it is off limits. Licensee stated that unit is used only for family members coming over to visiting her. LPA observed the back yard is fenced and there are not bodies of water. ***************Report dated 8/10/22 continues on page 2.

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Fermin Campos-Jaramillo	TELEPHONE: 408-334-8557
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022

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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Document Has Been Signed on 08/10/2022 04:51 PM - 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: VILLALOBOS, ROSA	FACILITY NUMBER: 434403885
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(m)(3)

Operation of A Family Child Care Home

(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review the licensee did not comply with the section cited above in 14 children's files., which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/25/2022
	Plan of Correction
1 2 3 4

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.

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Fermin Campos-Jaramillo	TELEPHONE: 408-334-8557
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022

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: VILLALOBOS, ROSA	FACILITY NUMBER: 434403885
	VISIT DATE: 08/10/2022

NARRATIVE

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Report dated 8/10/22 continues from page 1.

LPA observed a fully charged 3A40BC fire extinguisher, working smoke and carbon monoxide detectors. The Licensee states that she does not have any weapons in the home. All detergents, cleaning compounds, medications, and other similar items are stored inaccessible to children. Licensee has proof of the immunization for measles, pertussis and influenza according with the SB792.

Supervision of children was discussed with Licensee and she understands that she or a qualified adult must be present in the home during day care hours and ensure that the children are supervised at all times. The Licensee understands her capacity options and she understands that she cannot have more than 14 children in the home at any time and a helper must be present when she has more than 8 children in care, and ratio must be observed. Licensee stated she does not transport children via vehicle and she understands that children cannot be left in parked vehicles unattended at any time.
Department website: www.ccld.ca.gov provided to Licensees.

LPA discussed the requirements of AB 633 with the Licensee. LPA also discussed "zero tolerance" related regulations with the Licensee.
Licensee and her helper Martha have renewed their mandated reported training on 3/20/22 LPA informed licensee that all the adults in contact with children in her home are required to complete the training. LPA referred the Licensee to the training website: www.mandatedreporterca.com for additional information on the online training.
A review of staff records on 8/09/22 indicates tha all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

Report dated 8/10/22 continues on page 3.

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Fermin Campos-Jaramillo	TELEPHONE: 408-334-8557
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022

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: VILLALOBOS, ROSA	FACILITY NUMBER: 434403885
	VISIT DATE: 08/10/2022

NARRATIVE

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Report dated 8/10/22 continuers from page 2.

Licensee Rosa Villalobos was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/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.

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. 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: http://www.ada.gov/childqanda.htm

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/process.

Exit interview conducted and report was reviewed with the licensee Rosa Villalobos

One type B deficiency was cited today.

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

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Fermin Campos-Jaramillo	TELEPHONE: 408-334-8557
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022

LIC809 (FAS) - (06/04)

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