434405947-6-16-2023-07-CC-ALOZ-CSUPFF-20230616111640

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434405947
Report Date: 06/16/2023
Date Signed: 06/16/2023 11:16:46 AM

Document Has Been Signed on 06/16/2023 11:16 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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	GOMEZ, MARICELA		FACILITY NUMBER:	434405947
ADMINISTRATOR:	GOMEZ, MARICELA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 269-8711
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95124
CAPACITY:	14	CENSUS: 8	DATE:	06/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Maricela Gomez		TIME COMPLETED:	11:30 AM

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 Analyst (LPA) Ashley Lopez met with Licensee, Maricela Gomez, for an unannounced Required – 1-year annual inspection. LPA was granted access to the home by the Licensee. LPA also observed 8 of children (1 infant and 7 preschool children) and 1 adult assistant in the home during today's inspection. Licensee was operating within her capacity and ratio requirements. LPA observed the required postings, including the facility license. Days and hours of operation are Monday - Friday from 7:00am-5:30pm. The adults residing in the home are: Licensee, Licensee's spouse, and adult daughter. 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 5/14/23. Licensee states that she does have liability insurance for the day care through DCI. Licensee, husband, and assistant have current CPR and First Aid certifications (exp: 5/2024 and 12/2023). Licensee has the required vaccines (MMR, Tdap, & flu declination) and is current with her Mandated Reporter Training for Child Care Workers (exp: 12/2023). Assistant has the required vaccines (Tdap and TB), but is missing proof of the MMR vaccine. Assistant is current with her Mandated Reporter Training for Child Care Workers (exp: 12/2023). LPA reviewed 7 children's files and the files were complete with the required forms. LPA reviewed 1 staff file and the files were complete with the required forms. ---------------------------------continued on page 2--------------------------------------------

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Ashley Lopez	TELEPHONE: (916) 798-3658
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

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: GOMEZ, MARICELA	FACILITY NUMBER: 434405947
	VISIT DATE: 06/16/2023

NARRATIVE

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LPA toured the indoor and outdoor areas of the home during today's inspection. Licensee has a working telephone in the home (408)269-8711. The home is clean and orderly, and safe for the day care children. There are safe & age-appropriate toys, play equipment, and materials for the children in the home. There are stairs inside the home, they are barricaded by a gate to make inaccessible to children in care. LPA observed a barricaded fireplace inside the home. Off limit areas inside the home are the second floor and the garage. Off limit areas outside the home are the right and left sides of the backyard which are gated and locked.

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 in the home. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children. Licensee states that she does not administer any medications to the day care children. Licensee has a first aid kit in the home. Licensee states that nobody smokes, and she understands that smoking is prohibited in the home.

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

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SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Ashley Lopez	TELEPHONE: (916) 798-3658
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

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: GOMEZ, MARICELA	FACILITY NUMBER: 434405947
	VISIT DATE: 06/16/2023

NARRATIVE

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Supervision of children was discussed with the Licensee, 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 understands their capacity/ratio options and they understand that they cannot have more than 14 children present in the home. Licensee states that a child will be isolated in another room/area if necessary due to illness or communicable disease and parents will be contacted immediately. Licensee states that they do not transport any day care children. 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.

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.

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 advised licensee about logging the infants naps in a sleep log, and to check on the infant every 15 minutes.

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 Maricela Gomez.
Deficiencies issued during today's inspection. A Notice of Site Visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Ashley Lopez	TELEPHONE: (916) 798-3658
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/16/2023 11:16 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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GOMEZ, MARICELA	FACILITY NUMBER: 434405947
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1597.622(c)

Administration of Child Day Care Licensing

(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee does not have proof of Assistant's immunization for measles (MMR) which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/23/2023
	Plan of Correction
1 2 3 4	Licensee will submit proof of immunization for measles (MMR) for assistant to licensing by 6/23/23.

Type B

Section Cited

CCR

102425(j)(2)(D)(c)

Infant Safe Sleep

Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee does not have a 15 minute check nap log for infants in care which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/23/2023
	Plan of Correction
1 2 3 4	Licensee will submit proof of 15 minute nap check sleep log to licensing by 6/23/23.

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: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Ashley Lopez	TELEPHONE: (916) 798-3658
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

LIC809 (FAS) - (06/04)

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