434406635-6-29-2023-07-CC-DVIA-CT9UBF-20230629152617

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434406635
Report Date: 06/29/2023
Date Signed: 06/29/2023 03:26:31 PM

Document Has Been Signed on 06/29/2023 03:26 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:	GARCIA, BLANCA		FACILITY NUMBER:	434406635
ADMINISTRATOR:	GARCIA, BLANCA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 347-0664
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95116
CAPACITY:	14	CENSUS: 5	DATE:	06/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Blanca Garcia		TIME COMPLETED:	03:35 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 Analyst (LPA) Deanna Villagrana met with licensee Blanca Garcia for a required one year visit. LPA explained the nature of today’s inspection to her. Present were licensee, licensee's 19 year old grandson, 13 year old granddaughter, 11 month old grandson and three day care children. Licensee's neighbor came to the home during visit to provide medication to licensee. Days and hours of operation are Monday to Friday, 6:00am to 6:00pm. The adults that reside in the home are licensee, her adult daughter and 19 year old grandson Emiliano Dominguez. A review of staff records on 05/30/2023 indicates that not all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Emiliano Dominguez does not have fingerprint clearance. Licensee Blanca Garcia 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 toured the indoor and outdoor areas of the home during today’s inspection. LPA observed that the home is clean and orderly, with heating and ventilation for safety and comfort of the children. Upon arrival, LPA observed a child strapped into a stroller watching TV. LPA asked why child was in stroller. Licensee stated because she did not want child to bite other children. During the visit, licensee left the home to taker her grandson to her daughter's home next door. Licensee left the children without a CPR/First Aid certified adult in the home. LPA observed a barricaded fireplace in the home. LPA observed safe and sufficient materials, toys, and play equipment for the day

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna Villagrana	TELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023

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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GARCIA, BLANCA	FACILITY NUMBER: 434406635
	VISIT DATE: 06/29/2023

NARRATIVE

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care children. All sharp objects, detergents, cleaning compounds, medications, poisons, and other similar items inside the home are stored inaccessible to children. LPA observed a bucket of water accessible to children. The bucket had approximately a foot of water in it. LPA observed a fully charged 3A40BC fire extinguisher and a working smoke detector. LPA did not observe a working carbon monoxide detector. Licensee states there are no weapons/firearms in the home. Off limit areas indoor: two bedrooms, two bathrooms and attached garage. Backyard is fenced. Off limits outdoor: backyard. Licensee states she has one dog is vaccinated. LPA observed licensee has a current CPR and First Aid certification expiring 10/15/2024. Licensee has not completed Mandated Reporter training.

LPA did not observe a current roster of the children. LPA did not observe a fire and disaster drill log. LPA reviewed four children's files. Child 2 and 4 are missing LIC627. Child 2 is missing LIC995. Child 1, 2 and 4 do not have immunization records on file. Licensee did not have a Safe Sleep log for infant in care. Licensee states day care is not insured. LPA discussed SB792 Immunization Requirements and observed licensee has immunization records on file.

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. Licensee understands her capacity options and she understands that she cannot have more than 14 children in the home at any time. Licensee understands if she transports children via vehicle, children cannot be left in parked vehicles unattended at any time.

LPA discussed the safe sleep regulations with licensee Blanca Garcia 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 licensee Blanca Garcia 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 discussed Zero Tolerance related regulations with licensee Blanca Garcia and was advised of the assessment of $500 immediate civil penalty and an ongoing $100 per day per violation continues until the violation(s) is corrected. Incidental Medical services (IMS) policy was discussed. For IMS information see Evaluator Manual – Regulation

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna Villagrana	TELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023

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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GARCIA, BLANCA	FACILITY NUMBER: 434406635
	VISIT DATE: 06/29/2023

NARRATIVE

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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 Blanca Garcia. During the exit interview, licensee Blanca Garcia, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

The following type A and B deficiencies were cited on the attached page (809-D). Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction (POC) Due Date may result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.

LPA Deanna Villagrana informed licensee Blanca Garcia that this report dated 06/29/2023 document(s) 3 Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Deanna Villagrana informed the licensee Blanca Garcia to provide a copy of this licensing report dated 06/29/2023 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

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

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Report was read and signed by daughter Blanca Garcia and approved by licensee.

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna Villagrana	TELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023

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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GARCIA, BLANCA	FACILITY NUMBER: 434406635
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

102417(g)(5)

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: (5) All licensees shall ensure the inaccessibility of pools (in-ground and above-ground), fixed-in-place wading pools, hot tubs, spas, fish ponds and similar bodies of water through a pool cover or by surrounding the pool with a fence. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPA observed a bucket of water accessible to children. The bucket had approximately a foot of water in it which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/29/2023
	Plan of Correction
1 2 3 4	Licensee removed the water and emptied the bucket. Deficiency cleared today.

Type A

Section Cited

CCR

102370(d)(1)

Criminal Record Clearance

(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above. Emiliano Dominguez does not have fingerprint clearance which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/30/2023
	Plan of Correction
1 2 3 4	Licensee will have grandson fingerprint cleared immediately and understands grandson may not be present in the home until he is cleared.

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: Deanna Villagrana	TELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023

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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GARCIA, BLANCA	FACILITY NUMBER: 434406635
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

102423(a)(4)

Personal Rights

(a) Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to, the following: (4) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including, but not limited to: interference with eating, sleeping or toileting; or withholding shelter, clothing, medication or aids to physical functioning. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPA observed a child strapped into a stroller watching TV which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/29/2023
	Plan of Correction
1 2 3 4	Licensee removed child during visit. Deficiency cleared today.

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: Deanna Villagrana	TELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023

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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GARCIA, BLANCA	FACILITY NUMBER: 434406635
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1597.543

Licensure Requirements

Every family day care home for children shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 Division 12. The department shall account for the presence of these detectors during inspections. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPA did not observe a working carbon monoxide detector which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/30/2023
	Plan of Correction
1 2 3 4	Licensee will submit a photo of a new carbon monoxide detector installed to CCLD by POC date.

Type B

Section Cited

CCR

102417(g)(9)(A)

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. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above. LPA did not observe a fire and disaster drill log which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Licensee will conduct a fire and disaster drill and submit to CCLD by POC date.

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: Deanna Villagrana	TELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023

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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GARCIA, BLANCA	FACILITY NUMBER: 434406635
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/29/2023

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
1 2 3 4	Based on interview, the licensee did not comply with the section cited above. Licensee has not completed Mandated Reporter training which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Licensee will completed training and submit a current Mandated Reporter Certificate to CCLD by POC date. Training can be found at www.mandatedreporterca.com.

Type B

Section Cited

CCR

102416(c)

Personnel Requirements

(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. Licensee left the children without a CPR/First Aid certified adult in the home which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/29/2023
	Plan of Correction
1 2 3 4	Licensee understands the day care must have at least one person present who is CPR/First Aid certified in the home while children are present. Deficiency cleared today.

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: Deanna Villagrana	TELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023

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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GARCIA, BLANCA	FACILITY NUMBER: 434406635
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102418(a)

Immunizations

(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. Child 1, 2 and 4 do not have immunization records on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Licensee will submit immunization records for child 1, 2 and 4 to CCLD by POC date.

Type B

Section Cited

CCR

102417(g)(7)

Operation of A Family Child Care Home

(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. Child 2 and 4 are missing LIC627 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Licensee will submit LIC627 for child 2 and 4 to CCLD by POC date.

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: Deanna Villagrana	TELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023

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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GARCIA, BLANCA	FACILITY NUMBER: 434406635
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(8)

Operation of A Family Child Care Home

(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above. LPA did not observe a current roster of the children] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Licensee will submit a current roster to CCLD by POC date.

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: Deanna Villagrana	TELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023

LIC809 (FAS) - (06/04)

Page: 9 of 11

Document Has Been Signed on 06/29/2023 03:26 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: GARCIA, BLANCA	FACILITY NUMBER: 434406635
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102419(d)(1)

Admission Procedures and Authorized Representatives Rights

(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or authorized representative has received and read the LIC 995A. The bottom portion of this form must be kept in the child’s file as proof that the parent or authorized representative has been notified of his or her rights and received a copy of the Caregiver background Check Process, LIC 995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. Child 2 is missing LIC995 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Licensee will submit LIC995 for child 2 to CCLD by POC date.

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: Deanna Villagrana	TELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023

LIC809 (FAS) - (06/04)

Page: 10 of 11

Document Has Been Signed on 06/29/2023 03:26 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: GARCIA, BLANCA	FACILITY NUMBER: 434406635
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(j)(2)(D)

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: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, the licensee did not comply with the section cited above. Licensee did not have a Safe Sleep log for infant in care which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/11/2023
	Plan of Correction
1 2 3 4	Licensee will submit a Safe Sleep log for week of 07/03/2023-07/07/2023 to CCLD by POC date.

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: Deanna Villagrana	TELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023

LIC809 (FAS) - (06/04)

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