434406818-4-26-2023-07-CC-TTRO-CR9P36-20230426105700

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434406818
Report Date: 04/26/2023
Date Signed: 04/26/2023 10:57:06 AM

Document Has Been Signed on 04/26/2023 10:57 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:	MADRIGAL, MARIA LOURDES		FACILITY NUMBER:	434406818
ADMINISTRATOR:	MADRIGAL, MARIA LOURDES		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 286-7904
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95110
CAPACITY:	14	CENSUS: 5	DATE:	04/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:25 AM
MET WITH:	Maria Lourdes Madrigal		TIME COMPLETED:	11:15 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

On 04/26/2023 at 8:25 AM, Licensing Program Analyst (LPA) Teodoro Trujillo met with licensee, Maria Lourdes Madrigal, for an annual inspection and explained the reason for the visit to her. Present during today's visit were licensee with 5 children: two (2) infants and 3 preschool age, assistant Maria and one (1) infant child (1) on preschool child arrived during site visit. Adults living in the home are licensee and, her spouse. Days and hours of operation are Monday through Friday 06:00 AM to 06:00 PM.

A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 4/24/2023 was reviewed and it indicates that all Facility staff or other individuals who require caregiver background clearances have received criminal record and child abuse index clearances or exemptions. 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 inspected inside and outside of home. LPA observed a no fireplace, no wall heater, no stairs, and no bodies of water. Licensee stated there are no weapons. Licensee stated she no pets. LPA observed a 3A40BC fire extinguisher last serviced 03/02/2023. A combination Carbon Monoxide/smoke detector is operable. Sharp objects, medicines, poisons, and cleaning supplies were inaccessible to the children in care. Off limit areas inside the home: master bedroom and bathroom, attached garage, and bedroom. On limit areas: computer room, living room, hallway bathroom, bedroom next to bathroom, and kitchen. On limit areas outside the home: rear back yard. Off limit outside: gated left and right side yard area.

Children were supervised during the visit and LPA went over substitute options and reminded licensee they could only have 14 children according to her license. Licensee stated she does not transport children, LPA reminded Licensee that children are never to be left in parked vehicles and must use appropriate car seats according to the child's age/weight/size.

Continues report dated 04/26/2023 pg. 1/2

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro Trujillo	TELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

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 2

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: MADRIGAL, MARIA LOURDES	FACILITY NUMBER: 434406818
	VISIT DATE: 04/26/2023

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
26
27
28
29
30
31
32

Continuation of report dated 04/26/2023 pg. 2/2
LPA observed a current roster of the children. LPA observed a fire and disaster drill log last performed on 03/15/2023. LPA reviewed 5 children’s files and observed all required documentation was in compliance. Infant individual sleeping plan (LIC 9227) for each infant under 12 months was provided and discussed and a 15 minute check sleep log for infants under 24 months was discussed.. LPA observed licensee completed Mandated Reporter Training on 01/22/22, assistant Maria completed 01/22/22. Licensee has Pediatric CPR/1^st Aid that expiring on 02/10/2024, assistant Maria expires 04/02/2025. Needed documentation for SB 792 which requires immunization against Pertussis, Measles, and Influenza as well as TB testing is current for licensee, and all adults helping or residing in the home.

Incidental Medical Services (IMS) policy was discussed with the licensee. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The licensee is not providing IMS currently. Licensee will submit an updated plan of operation if in the future they provide any IMS services to a child in care.

LPA discussed the safe sleep regulations with 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 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.

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.

No deficiencies were cited during today's visit. Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction Due Date will result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.

Exit interview conducted and report was reviewed in Spanish with the licensee, Maria Lourdes Madrigal. 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.

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro Trujillo	TELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2