434407880-7-28-2021-07-CC-SYIP-C5CRSZ-20210728131735

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434407880
Report Date: 07/27/2021
Date Signed: 07/28/2021 01:17:40 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:	LUCERO, PATRICIA		FACILITY NUMBER:	434407880
ADMINISTRATOR:	LUCERO, PATRICIA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 846-2823
CITY:	GILROY	STATE: CA	ZIP CODE:	95020
CAPACITY:	14	CENSUS: 8	DATE:	07/27/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:06 AM
MET WITH:	Patricia Lucero		TIME COMPLETED:	11:45 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	Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Required 1- Year inspection. LPA met with Licensee Patricia Lucero and explained the reason for the inspection. Present during today's inspection were Licensee, her assistant, and 8 children, whom 2 were infant age. There is board to post required postings. There is working phone in the home. The hours of operation are Monday through Friday 7AM to 530PM. LPA toured the inside and outside of the home. The off-limit areas of the home are the master bedroom, all four bedroom, the right and left side of the backyard. There is fireplace in the home, which has a cover around it. All cleaning supplies, disinfectant, and other items that are dangerous to children were inaccessible to children. LPA reminded Licensee that any knives that are drying need to be stored inaccessible to children. There is sufficient amount of toys and equipment for children in care. There were no baby walkers observed during today's inspection. There is fully charged fire extinguisher, smoke detector, and carbon monoxide detector. The last fire drill was conducted on 05/2021. LPA reminded Licensee that fire drill need to be documented. Licensee stated that there are no weapons, such as firearms, stored in the home. The backyard is used and is fenced. There is play structure in the backyard, which is anchored to the ground. LPA observed that there was a tube of Destin in the changing table outside. LPA reminded Licensee that any diaper creams need to be inaccessible to children. There were no bodies of water observed during today's inspection. -----------------------CONTINUES ON 809 DATED 07/27/2021 PAGE 2-----------------------------

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021

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: LUCERO, PATRICIA	FACILITY NUMBER: 434407880
	VISIT DATE: 07/27/2021

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 809 DATED 07/27/2021 PAGE 1----------------------

Licensee stated that she does not transport children at this time, but understands that children cannot be left alone and unattended in parked vehicles. Licensee stated that she does not provide Incidental Medical Services (IMS).

A copy of the facility roster was obtained. 7 children's files were reviewed during today's inspection. The records reviewed include but not limited to Emergency Contact Card. LPA also discussed with Licensee about documenting that children under 2 years old are being checked every 15 minutes. C-1 had forms in the file, but was not signed. Licensee stated that she will have parent sign the forms and send it to Licensing by 5PM on 07/28/2021.

Licensee and her Assistant files were reviewed. Licensee and her assistant's immunization records for measles and pertussis are on file. Licensee has a valid CPR/1st Aid, which expires on 06/12/2023. Licensee and her assistant completed the Mandated Reporter training. Licensee completed the Mandated Reporter Training on 09/02/2019. LPA reminded Licensee that the Mandated Reporter Training needs to be renewed every 2 years.

The adults living in the home are Licensee, her Assistant/brother, and her adult son. All adults have cleared criminal records, child abuse index, or exemptions. Licensee stated that she will have one more adult moving in. Licensee stated that she will check to ensure that the adults living the home have cleared fingerprint before moving in. She stated that she will submit an updated LIC 279 and TB clearance for the adult living in the home.

As a result of this inspection, no deficiencies have been cited. An exit interview was conducted where this report was discussed and provided to Licensee Patricia Lucero. A Notice of Site Visit has been issued and must be posted for 30 consecutive days.

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021

LIC809 (FAS) - (06/04)

Page: 2 of 2