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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434406662
Report Date: 03/10/2020
Date Signed: 03/10/2020 04:06:02 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:PEREYRA, IRENEFACILITY NUMBER:
434406662
ADMINISTRATOR:IRENE PEREYRAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 842-5946
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY:14CENSUS: 11DATE:
03/10/2020
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Irene PereyraTIME COMPLETED:
04:15 PM
NARRATIVE
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LPA Deanna Villagrana met with licensee Irene Pereyra for an unannounced 1 year required visit. LPA explained the nature of today’s inspection to her. Present were licensee, licensee's assistant and 11 daycare children including four infants. Licensee's husband arrived a short time later. Days and hours of operation are Monday to Friday, 6:00am to 6:00pm. The adults that reside in the home are licensee, her husband and two foster kids ages 18 and 16 years old.
A review of staff records on 03/09/2020 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. Licensee Irene states foster child Jose Ruiz Montes (07/04/2001) lives in the home. LPA observed Jose does not have clearance. Licensee understands upon notice of the Department to remove an individual from the home, or to exclude an individual from the home, the licensee shall immediately remove the individual and prevents them from returning to the home or having contact with children in care.
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. LPA observed a barricaded fireplace in the home. LPA observed safe and sufficient materials, toys, and play equipment for the day care children. LPA observed a knife on the kitchen counter accessible to children. LPA observed a bouncer in the home. LPA observed a fully charged 3A40BC fire extinguisher. LPA observed a working smoke detector and a working carbon monoxide detector. Licensee states there are no weapons/firearms in the home. Off limit areas indoor: master bedroom/bath, four bedrooms, one bathroom and attached garage. LPA observed a bathroom in play room that is not shown on facility sketch. LPA asked if a permit was obtained to add bathroom. Irene stated no. LPA requested a new facility sketch. There are no bodies of water. Backyard is fenced. Off limits outdoor: fenced off area only used when licensee is present and locked storage. Licensee states they are not using backyard at this time because of the weather and that her husband is repairing a side fence. Licensee states she has two dogs, one cat and several birds.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 8
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: PEREYRA, IRENE
FACILITY NUMBER: 434406662
VISIT DATE: 03/10/2020
NARRATIVE
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LPA observed licensee and her assistant have current CPR and First Aid certification. Licensee’s expires 05/04/2021 and assistant's 05/26/2021. Licensee completed Mandated Reporter training on 01/29/2020. Assistant Myrna Ramon began working on January 24, 2020 and will complete soon.

LPA observed a current roster of the children and a fire and disaster drill log which was last completed on 11/11/2019. LPA reviewed 11 children's files. Child 10 is missing LIC995. Child 11 needs updated immunization records. LPA observed day care is insured with Farmers and expires 04/03/2020. LPA discussed SB792 Immunization Requirements and observed licensee has immunization against pertussis, measles and influenza. LPA observed there is not file for assistant Myrna. Assistant is missing LIC9052 and immunization against pertussis, measles and influenza. Assistant and Jose do not have a current tuberculosis and LIC508 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 Zero Tolerance with $500 immediate civil penalty. An ongoing $100 per day per violation continues until the violation(s) is corrected. LPA discussed the requirements of AB633 to licensee and provided her the AB633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and licensee understands the requirements. 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.

LPA reminded the Licensee that effective January 1, 2019 Assembly Bill 2370 requires that all licensed homes to share information on the risks and effects of lead exposure with enrolling and re-enrolling families. LPA provided a copy of the “Lead Poisoning Facts Information Flyer” to the Licensee. LPA advised the Applicant of the pending Department regulation update regarding safe sleep for infant children. LPA referred the Applicant to the Department website: www.ccld.ca.gov for additional information and provided licensee with a "Safe Sleep" handout.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2020
LIC809 (FAS) - (06/04)
Page: 2 of 8
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: PEREYRA, IRENE
FACILITY NUMBER: 434406662
VISIT DATE: 03/10/2020
NARRATIVE
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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.

An exit interview was conducted and Plans of Corrections were reviewed and developed with the Licensee. A copy of this report and appeal rights were discussed and let with licensee Irene, whose signature on this form confirms receipt of these documents.

Notice of site visit was issued and must be posted for 30 days.

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2020
LIC809 (FAS) - (06/04)
Page: 3 of 8
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: PEREYRA, IRENE
FACILITY NUMBER: 434406662
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/11/2020
Section Cited

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102370(d)(1) Criminal Record Clearance. All individuals subject to a criminal record review as specified in Section 1596.871 prior to working, residing or volunteering in a licensed home, shall obtain a California clearance or a criminal record exemption as required by the Department.
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This requirement was not met as evidenced by LPA observed Jose does not have clearance. This poses an immediate risk to the Health, Safety or Personal Rights to children in care.
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AB633 Parent Notification is required.
This page shall be provided to all parents of children currently enrolled and any future children being enrolled for the next 12 months per AB633 requirements.
Type A
03/10/2020
Section Cited

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102417(g)(4) Operation of a Family Child Care Home. Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger to children shall be stored where they are inaccessible to children.
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This requirement was not met as evidenced by LPA observed a knife on the kitchen counter accessible to children. This poses an immediate risk to the Health, Safety or Personal Rights to children in care.
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AB633 Parent Notification is required.
This page shall be provided to all parents of children currently enrolled and any future children being enrolled for the next 12 months per AB633 requirements.
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 SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2020
LIC809 (FAS) - (06/04)
Page: 4 of 8
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: PEREYRA, IRENE
FACILITY NUMBER: 434406662
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/10/2020
Section Cited

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102417(g)(10) Operation of a Family Child Care Home. A baby walker is not permitted on the premises of a family child care home in accordance with Health and Safety Code Sections 1596.846(b) and (c).
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This requirement was not met as evidenced by LPA observed a bouncer in the home. This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Type B
03/20/2020
Section Cited

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102421(a) Childs Records. The licensee shall maintain, in each child’s record, the signed and dated notice form LIC 995A, Parents Rights Notice. This requirement was not met as evidenced by
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Child 10 is missing LIC995.
This poses a potential risk Health, Safety Personal Rights risk to children in care.
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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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2020
LIC809 (FAS) - (06/04)
Page: 5 of 8
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: PEREYRA, IRENE
FACILITY NUMBER: 434406662
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/20/2020
Section Cited

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102418(g) Immunization. Licensee shall document and maintain each child’s immunizations as long as the child is enrolled. This requirement was not met as evidenced by Child 11 needs updated immunization records.
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This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Type B
03/20/2020
Section Cited

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102416.1(a) Personnel Records. Personnel records shall be maintained on each employee and shall contain specified information. This requirement was not met as evidenced by
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LPA observed there is not file for assistant Myrna.
This poses a potential risk Health, Safety Personal Rights risk to children in care.
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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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2020
LIC809 (FAS) - (06/04)
Page: 6 of 8
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: PEREYRA, IRENE
FACILITY NUMBER: 434406662
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/20/2020
Section Cited

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102416.1(a)(10) Personnel Records. Personnel records shall contain a signed and dated copy of the Notice of Employee Rights (LIC 9052). This requirement was not met as evidenced by Assistant is
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missing LIC9052.
This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Type B
03/20/2020
Section Cited

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102416.1(a)(11) Personnel Records. Personnel records shall contain a signed statement regarding their criminal record history, and shall contain specified information. This requirement was
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not met as evidenced by Assistant and Jose do not have an LIC508 on file.
This poses a potential risk Health, Safety Personal Rights risk to children in care.
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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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2020
LIC809 (FAS) - (06/04)
Page: 7 of 8
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: PEREYRA, IRENE
FACILITY NUMBER: 434406662
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/20/2020
Section Cited

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102369(b)(9) Application for License. Licensees and any adult in the home, shall provide evidence of a current tuberculosis clearance, performed and signed by a physician not more than one year prior to or seven days after first day of employment.
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This requirement was not met as evidenced by assistant and Jose do not have a current TB test on file. This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Type B
05/11/2020
Section Cited

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1597.622 (a) (1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
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This requirement was not met as evidenced by Myrna does not have immunization against pertussis, measles and influenza on file. This poses a potential risk Health, Safety Personal Rights risk to children in care.
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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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2020
LIC809 (FAS) - (06/04)
Page: 8 of 8