434407664-4-11-2023-07-CC-FRAA-CQSMW5-20230411095746

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434407664
Report Date: 04/06/2023
Date Signed: 04/11/2023 09:58:00 AM

Document Has Been Signed on 04/11/2023 09:58 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:	GALSIM, MARIBEL		FACILITY NUMBER:	434407664
ADMINISTRATOR:	GALSIM, MARIBEL		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 528-7340
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95148
CAPACITY:	14	CENSUS: 10	DATE:	04/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	MARIBEL GALSIM		TIME COMPLETED:	04:05 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), Farida Raja, conducted an unannounced 1- year annual inspection. LPA was granted access to the home by Licensee's spouse, Arnulfo Galsim and explained the nature of today’s inspection. LPA observed 3 adults (Licensee's spouse- Arnulfo Galsim, Licensee's mother/staff - Mila Pimentel and Licensee's sister/staff- Janalin Pimentel) and 8 children( 2 infants, 6 preschool) in the home during today’s inspection. Two school age children arrived at 2:53pm. Licensee's sister stated that Licensee left around 11:30am because she received a call from the hospital that her aunt was in the emergency room. Licensee and sister- Juliet Pimentel arrived at 12:28 pm. Licensee was operating within the ratio and capacity requirements of her license. Days and hours of operation are Monday to Friday, 7:00 am to 6:00 pm. LPA observed all required posted materials in the living room of the home. Licensee stated that her pool was filled in in 2019. Licensee will submit an updated facility sketch. Licensee no longer requires a waiver. The adults that reside in the home are Licensee, Licensee's - spouse, mother, two(2) sisters, one adult son, one adult nephew and brother-in-law (Ariel Ramos). LPA observed that brother-in-law is not cleared and still 'in process' on Guardian. LPA toured the indoor and outdoor areas of the home during today's inspection. Licensee has a working telephone in the home (408-528-7340). LPA observed sufficient materials, toys, and play equipment for the day care children. Furniture, such as tables, chairs, feeding chairs and shelves, are in good condition. There were no baby walkers or bouncers observed on the premise during today’s inspection. The home has central heating/cooling and ventilation for comfort of children. The home is two story and LPA observed barricaded stairs during today's inspection. Off limit areas inside the home: kitchen, downstairs bedroom, entire second floor, living room, attached garage and barricaded fireplace in the living room on-limit area. Off limit areas outside the home: left and right side sections of the backyard. Backyard is fenced. LPA observed some play structures in the backyard that are safe and secure for the children. LPA observed that the half bathroom attached to the living room which is used by children was in operating condition. Toilets and faucet are clean and operable.

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (510) -56-5850
LICENSING EVALUATOR NAME: Farida Raja	TELEPHONE: (916) 566-5850
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

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: GALSIM, MARIBEL	FACILITY NUMBER: 434407664
	VISIT DATE: 04/06/2023

NARRATIVE

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LPA observed a fully charged 3A40BC fire extinguisher in the kitchen area and working smoke/carbon monoxide detectors. The Licensee states that she does not have any weapons or pets in the home. All detergents, sharp objects and other similar items are stored inaccessible to children.

Drinking water is readily available for children in the home via individual labeled water bottles and through a water dispenser. Licensee states that parents bring all meals for the day care children. Licensee understands that any food brought from home shall be labeled with each child's name and properly stored or refrigerated.

LPA reviewed a current Child Care Facility Roster and Fire/Disaster drill log during today's inspection. Fire/disaster drill was conducted on 03/10/2023. LPA obtained copy of children's roster. Children file review was completed. Six(6) random children’s files were reviewed during today's inspection. One infant file reviewed did not have the required Individual Infant Sleeping Plan (LIC 9227). Licensee does not have liability insurance for the day care and issues the Affidavit Regarding Liability Insurance for Family Child Care Home (LIC 282). LPA reviewed 15-minute sleep log for the two (2) infants in care today.

Staff file review was completed and found to be current and up to date. LPA reviewed three(3) staff files (Licensee and two adult assistants) and the files were complete with the required forms. Licensees Pediatric CPR/First Aid certification expired but she is scheduled for training on 04/08/2023. LPA verified scheduled training and obtained a confirmation printout. Licensee has proof of immunization in file for measles, pertussis and influenza, according with the SB792. Licensee and staff are current with Mandated Reporter Training for Child Care Workers which expires on 06/28/2023. Licensee understands the training is mandatory to all Licensees and adults in the home in contact will children and requires renewal every two years.

Supervision of children was discussed with Licensee, and she understands that she or a qualified adult 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 and a qualified assistant must be present. Licensee understands in absence of a helper her license capacity is reduced to 8 and ratio (age of the children) must be observed.

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

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (510) -56-5850
LICENSING EVALUATOR NAME: Farida Raja	TELEPHONE: (916) 566-5850
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

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: GALSIM, MARIBEL	FACILITY NUMBER: 434407664
	VISIT DATE: 04/06/2023

NARRATIVE

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exemption, prior to initial presence in a licensed Family Child Care Home. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12-month period.

LPA discussed "zero tolerance" related regulations and advised that the assessment of an immediate $500 per day civil penalty for any violation of a "zero tolerance" related regulation. A $500 immediate civil penalty and $100 per day violation until corrected is assessed for serious violations such as absence of supervision, accessible bodies of water, accessible firearms, refused entry of licensing staff, presence of an excluded person, and violations that result in illness or injury.

Licensee states that a child will be isolated and separated from others if necessary due to illness or communicable disease. Licensee states that she does not administer any medications to the day care children at this time. Incidental Medical Services (IMS) policy was discussed. The Licensee stated that she currently does not have any children in care who require IMS. 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 Americans with Disabilities Act (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.

Licensees stated that they transport school age children. LPA reminded Licensee that children cannot be left in parked vehicles unattended at any time, the motor vehicles used to transport children shall be maintained in safe operating conditions, and all vehicle occupants must be secured in an appropriate restraint system.

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@dess.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.

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (510) -56-5850
LICENSING EVALUATOR NAME: Farida Raja	TELEPHONE: (916) 566-5850
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

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: GALSIM, MARIBEL	FACILITY NUMBER: 434407664
	VISIT DATE: 04/06/2023

NARRATIVE

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One Type A and one Type B deficiency were cited today. Due to the issuance of a Type A Citation during today's inspection, a copy of this Licensing Report must be given to each existing parent by the end of today or next day child is in care, and to any newly enrolled parents/guardians enrolled over the next 12 months from the date of this report. In addition, a copy of the LIC 9224 Acknowledgement of Receipt of Licensing Reports must be signed by each parent and kept in each child's file.

In areas that were evaluated, regulatory violations were observed. Exit Interview was conducted, where this report, the citations, plan of corrections, and appeal rights were reviewed and discussed with Licensee, Maribel Galsim. Citations are issued on 809-D pages of this report. Licensee signed the report acknowledging receipt of documents. LPA reminded Licensee that failure to correct deficiencies by Plan of Correction Due Date may result in penalties of $100 per day per violation.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (510) -56-5850
LICENSING EVALUATOR NAME: Farida Raja	TELEPHONE: (916) 566-5850
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/11/2023 09:58 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: GALSIM, MARIBEL	FACILITY NUMBER: 434407664
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

102370(d)

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: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and observation, the licensee did not comply with the section cited above. Licensee's brother-in-law (Ariel Ramos) who resides at the home has not obtained clearance and is still 'in process' which poses an immediate health, safety or personal rights risk to persons in care. LPA reminded licensee that all persons working, residing or volunteering shall obtain a California clearance or a criminal record exemption as required by the Department.
	POC Due Date: 04/07/2023
	Plan of Correction
1 2 3 4	Licensee will have brother-in-law get fingerprinted and submit a letter of understanding stating that the individual will not be present at the home during daycare hours and in the future licensee will ensure that any staff or resident will be cleared before their presence in the childcare. Licensee provided letter of understanding during inspection 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: Gladys Kuizon	TELEPHONE: (510) -56-5850
LICENSING EVALUATOR NAME: Farida Raja	TELEPHONE: (916) 566-5850
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/11/2023 09:58 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: GALSIM, MARIBEL	FACILITY NUMBER: 434407664
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(c)

Infant Safe Sleep

An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above for one infant in care which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/20/2023
	Plan of Correction
1 2 3 4	Licensee will have parent/authorized representative complete form LIC 9227 and maintain it in child's file. Licensee will send completed form to LPA by Plan of Correction date of 04/20/2023.

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: Gladys Kuizon	TELEPHONE: (510) -56-5850
LICENSING EVALUATOR NAME: Farida Raja	TELEPHONE: (916) 566-5850
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

LIC809 (FAS) - (06/04)

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