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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434405031
Report Date: 05/05/2022
Date Signed: 05/05/2022 11:31:18 AM


Document Has Been Signed on 05/05/2022 11:31 AM - 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:LOZANO, PAULINAFACILITY NUMBER:
434405031
ADMINISTRATOR:PAULINA LOZANOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 227-1294
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY:14CENSUS: 8DATE:
05/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Paulina LozanoTIME COMPLETED:
11:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janette Cruz met with Paulina Lozano, Licensee, for unannounced Required 1-year annual inspection. LPA was granted access to the home by the Licensee. LPA also observed, Licensee's adult assistant, Karla Sepulveda, one infant and seven preschool day care children present in the home during today's inspection. The Licensee was operating within her capacity and ratio requirements. LPA observed the required postings, including the facility license, posted inside the home. Days and hours of operation are Monday - Friday from 6:00 AM to 5:30 PM. Licensee and her spouse, Hiram Lozano, are the adults residing in the home. All adults have clearances for Tuberculosis and Criminal Background/Child Abuse Index clearances. There are no active waivers for this facility. Licensee has current CPR and First Aid certifications (expiration: 02/05/24).

LPA reviewed a current Child Care Facility Roster and Fire/Disaster drill log during today's inspection. The last fire/disaster drill was completed on 01/16/2022. Licensee does not have an active Child Care Liability Insurance. LPA reviewed eight children's files which had some missing child immunization records.

LPA discussed the safe sleep regulations with the Licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed the 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.

LPA toured the indoor and outdoor areas of the home during today's inspection. Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play

SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette CruzTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2022
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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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: LOZANO, PAULINA
FACILITY NUMBER: 434405031
VISIT DATE: 05/05/2022
NARRATIVE
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equipment for the day care children. Licensee states that a child will be isolated in the dining room area of the home if necessary due to illness or communicable disease.

LPA observed the home is clean, orderly, and safe for the day care children. LPA also observed a screened fireplace. There are no open face heater units and access to stairs is gated inside the home. LPA observed a play yard surrounded with rubber mats for cushioning. Off limit areas in the home: entire second floor (4 bedrooms with 2 bathrooms) laundry room, dining room and living room. Off limit areas outside the home: left side of backyard.

LPA observed a fully charged 2A10BC fire extinguisher, working smoke/carbon monoxide detectors, no bodies of water, and fenced backyard. The Licensee states that she does not have any weapons and pets in the home. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children. All poisons are stored in high cabinets. The Licensee states that she does not administer medication to the day care children.

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

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. 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.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette CruzTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: LOZANO, PAULINA
FACILITY NUMBER: 434405031
VISIT DATE: 05/05/2022
NARRATIVE
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Supervision of children was discussed with Licensee and she understands that she 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 without a fully qualified adult present. Licensee states that she does not transport any day care children. The Licensee understands that children shall not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.

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.

LPA provided Licensee with website resources on managing food allergies at school and handling medical emergencies related to food allergies.

CDC Managing Food Allergies at School
https://www.cdc.gov/healthyschools/foodallergies/index.htm

American Academy of Pediatrics Healthy Children Medical Emergencies
https://www.healthychildren.org/English/health-issues/injuries-emergencies/Pages/When-to-Call-Emergency-Medical-Services-EMS.aspx

Exit interview conducted and report was reviewed with the Licensee, Paulina Lozano. As a result of todays inspection, deficiencies are cited on the following page.

A Notice of Site Visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette CruzTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/05/2022 11:31 AM - 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: LOZANO, PAULINA
FACILITY NUMBER: 434405031

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 observation, interview and record review, the licensee did not comply with the section cited above. The Licensee and her adult assistant did not have a current Mandated Reporter Training Certificate upon inspection which pose a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/06/2022
Plan of Correction
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Licensee will submit to LPA the Mandated Reporter training certificates for herself, and her adult assistant by POC date 6/6/22.
Type B
Section Cited
CCR
102416.1(d)
Personnel Records
(d) All personnel records shall be maintained at the child care home and shall be available to the licensing agency for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above. Licensees' adult assistant did not have personnel records readily available for licensing agency to review which pose a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/06/2022
Plan of Correction
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Licensee will maintain and submit to LPA complete personnel records as required but not limited to: LIC508Criminal Record Statement, LIC9052 Employee Rights, Proof of Immunizations (measles, pertussis, flu), Tuberculosis clearance, LIC 9108 Statement Acknowledging Requirement to Report Child Abuse for all adult assistants providing care to children in her daycare.

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: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette CruzTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 05/05/2022 11:31 AM - 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: LOZANO, PAULINA
FACILITY NUMBER: 434405031

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above. Licensee did not obtain immunization records for five children enrolled which pose a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/06/2022
Plan of Correction
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Licensee will obtain and submit to LPA the immunization records of five children enrolled by POC date 06/06/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette CruzTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5