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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434404072
Report Date: 03/01/2023
Date Signed: 03/01/2023 01:08:47 PM


Document Has Been Signed on 03/01/2023 01:08 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:PASTORA, RUBIFACILITY NUMBER:
434404072
ADMINISTRATOR:PASTORA, RUBIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 223-7907
CITY:SAN JOSESTATE: CAZIP CODE:
95135
CAPACITY:14CENSUS: 3DATE:
03/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Rubi PastoraTIME COMPLETED:
01:15 PM
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Licensing Program Analysts(LPAs), Farida Raja and Joseph Macias conducted an unannounced 1- year annual inspection. LPA was granted access to the home by Licensee and explained the nature of today’s inspection. LPA observed 2 adults (Licensee and Husband) and 3 children (preschool aged) in the home during today’s inspection. Licensee's husband helps with daycare children. Licensee was operating within the ratio and capacity requirements of her license. Days and hours of operation are Monday to Friday 6:00 am to 6:00 pm. LPA observed all required posted materials, near the front entrance to the home. The adults that reside in the home are licensee and husband.

LPA toured the indoor and outdoor areas of the home during today's inspection. Licensee has a working telephone in the home (408-223-79078, cell phone 408-693-5297). LPA inspected home for any health and safety hazards. LPA observed age-appropriate materials, toys, and play equipment in the facility. Furniture, such as tables, chairs, cribs, feeding chairs and shelves, are in good condition. The home has central heating/cooling and ventilation. A thermostat was observed. The home is two story and LPA observed barricaded stairs to the lower level during today's inspection. Off limit areas inside the home: entire upstairs, downstairs(living room, dining area, kitchen and laundry room) and attached garage. A closed and barricaded fireplace was observed in the on limits family room. Off limit areas outside the home: left side section and storage shed. Backyard is fenced and both sides of the home are gated. LPA observed a play structure in the backyard that is safe and secure for the children. There are no bodies of water. A fountain was observed in the right corner of the backyard. LPA advised Licensee to fill fountain with rocks and send a confirmation picture to LPA.

LPA observed a fully charged 2A10BC fire extinguisher and a fire pull alarm in the family room area and working smoke/carbon monoxide detectors. The Licensee states that she does not have any weapons or pets in the home. All detergents, cleaning compounds, medications, sharp objects and other similar items are stored inaccessible to children. All poisons are inaccessible to children. Licensee has a first aid kit in high kitchen cabinets in the home. Licensee understands that smoking is prohibited in the home.
SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (510) -56-5850
LICENSING EVALUATOR NAME: Farida RajaTELEPHONE: (916) 926-9269
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2023
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: PASTORA, RUBI
FACILITY NUMBER: 434404072
VISIT DATE: 03/01/2023
NARRATIVE
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Licensee states that she provides breakfast, lunch, dinner (sometimes)and snacks to the children in care. Drinking water is readily available for children in the home via individual water bottles. Licensee understands that any food brought from home shall be labeled with each child's name and properly stored.

LPA reviewed a current Child Care Facility Roster and Fire/Disaster drill log during today's inspection. Fire/disaster drill was conducted on December 8, 2022. LPA obtained copy of children's roster. Three (3) children's files were review and found to have some forms missing. A technical advisory was given to update each child's file with required forms. Licensee states that she does not have liability insurance for the day care and issues the Affidavit Regarding Liability Insurance for Family Child Care Home (LIC 282). LPA reviewed two staff files (Licensee and spouse) and the files were complete with the required forms. Licensee and husband have current CPR and First Aid certifications (expiration: 01/02/2025). Licensee and spouse have the required MMR and TDAP vaccines. LPA observed that Licensee has not completed the required mandated reporter training. 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. Licensee stated that she will send a copy to LPA once training is completed. LPA reminded Licensee that Mandated Reporter Training must be renewed by all staff every 2 years.

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 qualified assistant must be present. Licensee understands in absence of a helper her license capacity is reduced to 8 and ratio (age of the children) must be observed.

Licensee 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. 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 violation within a 12 month period.
SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (510) -56-5850
LICENSING EVALUATOR NAME: Farida RajaTELEPHONE: (916) 926-9269
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
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: PASTORA, RUBI
FACILITY NUMBER: 434404072
VISIT DATE: 03/01/2023
NARRATIVE
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LPA reviewed with licensee the violations that would result in an immediate assessment of civil penalty in the amount of $500 ("zero tolerance"). Licensee is encouraged to visit the Department’s website at www.cdss.ca.gov [Shortcut: www.ccld.ca.gov] to access resources for Providers, Regulations, Adoptions of new laws, pay annual fees etc.

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 provided Licensee with information on Safe Sleep Regulations and 15- minute check for infants.

Licensee states that a child will be isolated in the living room and away from other children due to illness or communicable disease until parent pick-up. Licensee states that she does not administer any medications to the day care children at this time. 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.

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.



Licensees stated that her husband does transport children. LPA reminded Licensee that children cannot be left in parked vehicles unattended at any time, the motor vehicles used to transport children shall be maintained in safe operating conditions, and all vehicle occupants must be secured in an appropriate restraint system.

Exit interview conducted and report was reviewed with the Licensee, Rubi Pastora. Licensee agreed to submit a copy of the certificate of completion of the "mandated reporter" training, LIC 610 A Emergency Disaster Plan and copies of the completed children's files by Plan Of Correction date of April 3 and March 15, 2023 respectively.

As a result of today's inspection, there were 2 TYPE B deficiencies cited.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS
SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (510) -56-5850
LICENSING EVALUATOR NAME: Farida RajaTELEPHONE: (916) 926-9269
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 03/01/2023 01:08 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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131


FACILITY NAME: PASTORA, RUBI
FACILITY NUMBER: 434404072

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee does not have an Emergency Diaster Plan (LIC 610 A) for review at facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/16/2023
Plan of Correction
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Licensee will submit a completed Emergency Diaster Plan (LIC 610A) by Plan of Correction date of 15 March, 2023.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee and spouse who works with children do not have a current mandated reporter training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2023
Plan of Correction
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Licensee will submit a completed Mandated Reporter Training Certificate for licensee and spouse by Plan of Correction date of 3 April, 2023.
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: Gladys KuizonTELEPHONE: (510) -56-5850
LICENSING EVALUATOR NAME: Farida RajaTELEPHONE: (916) 926-9269
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2023
LIC809 (FAS) - (06/04)
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