434404726-8-1-2019-07-CC-JTSE-BEMQGW-20190801121013

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434404726
Report Date: 08/01/2019
Date Signed: 08/01/2019 12:10:21 PM

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:	RIVERA, FELICITAS		FACILITY NUMBER:	434404726
ADMINISTRATOR:	RIVERA, FELICITAS		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 259-2064
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95127
CAPACITY:	14	CENSUS: 10	DATE:	08/01/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Felicitas Rivera		TIME COMPLETED:	12:20 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	LPAs Janet Tse and Susy Cervantes met with licensee Felicitas Rivera for an annual/random inspection. Present were ten children including one infant with Licensee and her two assistants (IT & TZ). Licensee's infant grandchild was with Licensee's daughter-in-law in the main house. Adults living in the home are Licensee, her husband, her son, her daughter-in-law, and her daughter with a nine months old child. Days and hours of operation are Monday to Friday, 5:00am to 6:00pm. LPAs toured the indoor and outdoor of the home. LPAs observed a wall heater without screen. Licensee stated the wall heater is not functioning; and the home has central air conditioning/heating. The living room is used for infant napping only. LPAs observed a playpen in the living room. Off limits indoor: living room, all three bedrooms, and one bathroom. There are no bodies of water. Licensee stated there is no firearms/weapons in the home. Sharp objects, medicines, poisons and cleaning supplies were inaccessible to the children. Outdoor area is fenced. LPAs observed a covered patio and a dog run with three dogs in the backyard. Licensee stated that the dogs are vaccinated. Off limits outdoor: detached garage which is used for storage, the workshop adjacent to the garage, the vegetable garden, left side yard which is used as a car port, and the fenced off area. LPAs reminded Licensee that she can only has 14 children according to her license. Fire extinguisher is size 3A40BC and filled. Smoke and carbon monoxide detectors are operable. Home is clean and orderly with heating and ventilation for safety and comfort. LPAs observed sufficient materials, toys, and play equipment for the day care children. Telephone is in working order. Children were supervised on the visit and LPAs went over substitute options. LPAs also discussed if Licensee transports children, they are never to be left in parked vehicles, and car seat laws shall be followed. A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 07/31/2019 was reviewed; and it indicates that all Facility staff or other individuals Facility Evaluation Report dated 08/01/2019 to be continued on next page:

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet Tse	TELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2019

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: RIVERA, FELICITAS	FACILITY NUMBER: 434404726
	VISIT DATE: 08/01/2019

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Facility Evaluation Report dated 08/01/2019 to be continued from previous page:

who require caregiver background checks have received criminal clearances and child abuse index clearances or exemptions.

LPAs observed fire drill log which is to be done every 6 months. LPAs observed the last fire drill was done on 06/11/2019. A copy of the current roster of the children was provided to LPAs today. LPAs observed that Licensee and her assistant (TZ &IT) have current Pediatric CPR/1^st Aid expiring 05/20/2021, 12/16/2019, and 05/20/2021 respectively. LPAs obtained an updated LIC 279 Application for a Family Child Care Home with current information.

LPAs discussed the immediate civil penalties for Zero Tolerance of $500; and an ongoing $100 per day per violation continues until the violation(s) is corrected. 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. LPAs discussed the Healthy Beverage Act and AB633 requirements for A violations.

SB792 Immunization Requirements was discussed. LPA observed the required immunization records are in file. Licensee was provided a list of the current forms for child care. Information on Safe Sleep practice and Lead Poisoning was provided to Licensee. An exit interview was conducted.

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: Janet Tse	TELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2019

LIC809 (FAS) - (06/04)

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