434407797-7-6-2021-07-CC-JTSE-C4NQD8-20210706120418

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434407797
Report Date: 07/06/2021
Date Signed: 07/06/2021 12:04:28 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:	PEREZ, HERLINDA		FACILITY NUMBER:	434407797
ADMINISTRATOR:	PEREZ, HERLINDA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 998-4531
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95112
CAPACITY:	14	CENSUS: 6	DATE:	07/06/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Herlinda Perez		TIME COMPLETED:	12:15 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	(1)LPA Janet Tse met with licensee Herlinda Perez to conduct a Required - 1 Year inspection. LPA explained the nature of today's visit to Licensee. Present were six children with Licensee and her assistant (YH). Licensee's adult sons were also in the home. Adults living in the home are Licensee, her husband, two adult sons, an adult daughter, with a 17 1/2-year-old child. Days and hours of operation are Monday to Friday, 6:00am to 6:00pm, Saturday and Sunday for emergency only. LPA toured the inside and outside of the home. LPA observed a covered fireplace and no wall heaters. LPA observed stairs to the backyard is barricaded from the bottom. Off limits indoor: two bedrooms. There are no bodies of water. Licensee stated there is no firearms/weapons in the home. Medicines, poisons and cleaning supplies are inaccessible to the children. Storage areas for poisons are locked. Backyard is fenced. Off limits outdoor: storage room, basement, and the converted detached garage. Licensee's adult sons are living in the converted garage. LPA reminded licensee that she can only have 14 children according to her license. Licensee also understands her ratio and capacity options. Fire extinguisher is size 2A10BC and filled. Smoke and carbon monoxide detectors are operable. Home is clean and orderly with heating and ventilation for Facility Evaluation Report dated 07/06/2021 to be continued on next page: - Pg 1 of 4 -

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet Tse	TELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2021

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: PEREZ, HERLINDA	FACILITY NUMBER: 434407797
	VISIT DATE: 07/06/2021

NARRATIVE

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Facility Evaluation Report dated 07/06/2021 to be continued from previous page:
safety and comfort. LPA observed sufficient materials, toys, and play equipment for the dayvcare children. LPA observed Licensee is providing safe, healthful, and comfortable accommodations, furnishings, and equipment. Telephone is in working order.

Children were supervised on the visit and LPA went over substitute options. Licensee also understands that when a child shows signs of illness or communicable disease, he/she shall be separated from other children. LPA also discussed if licensee transports children, they are never to be left in parked vehicles. LPA observed Licensee is following the current COVID-19 ordinances for the health and safety of the children.

A listing of staff criminal record clearances associated to this facility in Guardian system on 07/02/2021 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. LPA also reminded Licensee of the applicable civil penalties for those adults who have not received fingerprint clearance, are not associated to the license and who come in contact with or provide care and supervision to the children. Penalty amounts: $100 per person per day, minimum of $100 to a maximum of $500 per person for an initial violation, and a minimum of $100 to a maximum of $3000 per person for any subsequent violation within a 12-month period.
Facility Evaluation Report dated 07/06/2021 to be continued on next page: - Pg 2 of 4 -

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet Tse	TELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2021

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: PEREZ, HERLINDA	FACILITY NUMBER: 434407797
	VISIT DATE: 07/06/2021

NARRATIVE

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Facility Evaluation Report dated 07/06/2021 to be continued from previous page:
LPA observed each child’s record has a copy of the emergency information card that contains all of the information specified by regulation. LPA observed Licensee has completed training on preventive health practices, and has current Pediatric CPR/1^st Aid expiring 02/28/2023. LPA obtained a copy of the current roster of the children today.

LPA discussed the immediate civil penalties for Zero Tolerance of $500, and an ongoing $100 per day per violation continues until the violation(s) is corrected. Licensee understands that when notified by the Department, Licensee shall comply with the removal of any person from the facility, who has specified convictions or for other reasons. LPA also discussed any authorized employee of the Department may enter and inspect any place providing personal care and services at any time, with or without advance notice.

LPA discussed the infant safe sleep policies, regulations, and requirements. LPA explained LIC 9227 Individual Infant Sleeping Plan should be in the file of each infant up to 12 months of age. LPA explained the documentation for infant sleep supervision which is maintained in each infant’s file includes date, infant’s name, and time of each 15 minutes check. Currently, Licensee does not have any infants enrolled. Licensee also understands that car seats can only be used for transportation and shall not be used for sleeping.

AB792 Immunization Requirements was discussed. LPA observed the required immunization records for Licensee and her assistant were in file.
Facility Evaluation Report datd 07/06/2021 to be continued on next page: - Pg 3 of 4 -

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet Tse	TELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2021

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: PEREZ, HERLINDA	FACILITY NUMBER: 434407797
	VISIT DATE: 07/06/2021

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Facility Evaluation Report dated 07/06/'2021 to be continued on next page:
The Mandated Reporter AB1207 Compliant Child Care Training was also discussed. Website to complete training: https://mandatedreporterca.com. A link to the alternate trainers approved to provide mandated reporter training: https://www.cdss.ca.gov/Portals/9/CCLD/CCP%20Documents/Approved%20Mandated%20Reporter%20Trainings.pdf. Licensee understands that the training is to be renewed every two years. Licensee and her assistant completed the training in February 8, 2020.

Website for provider resources: https://cdss.ca.gov/inforesources/Child-Care-Licensing. Periodic information releases accessible by signing up at: https://cdss.ca.gov/inforesources/community-care-licensing/subscribe.

No deficiency was cited. Notice of site visit was issued and must be posted for 30 days.
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SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet Tse	TELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2021

LIC809 (FAS) - (06/04)

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