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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434407945
Report Date: 02/26/2020
Date Signed: 02/26/2020 01:32:09 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:MAES, TINAFACILITY NUMBER:
434407945
ADMINISTRATOR:MAES, TINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 733-2950
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY:14CENSUS: 8DATE:
02/26/2020
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Tina MaesTIME COMPLETED:
01:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tuoc Doan conducted an unannounced Annual Inspection of the Family Day Care home. LPA met with Licensee Tina Maes and explained to her the purpose of the inspection. LPA observed Licensee and Assistant Provider/Daughter Shellina Medeiros providing care and supervision to the children. Upon entry into the home LPA observed eight children in care. At approximately 11:15 AM LPA reviewed the records kept for the eight children present. Based on the records, five of the eight children are infant age, which is younger than 2 years old. Licensee stated that she has only four infants in care and that the date of birth on Child 5's records is incorrect. Licensee called Child 5's mom and LPA spoke to Child 5's mom who confirmed Child 5's date of birth and that Child 5 is a little over two years old.

The home’s operating days and hours are Monday through Friday from 07:00 AM to 05:30 PM. The home maintains telephone service. The License and Notification of Parents’ Rights were observed to be posted. The home was inspected inside and out.

Licensee has a waiver granted on 03/23/2013 for day care children to use a Trampoline in the backyard. Per LPA's inspection today, Licensee no longer has a trampoline at the day care; therefore, the waiver is hereby rescinded. Also, Licensee informed LPA that she no longer has a Foster Family Home license at this address.

LPA did not observe flies, other insects, or rodents during the inspection. The observed children’s toys, play equipment, and furniture were in good condition. There were no baby walkers at the day care. Bathroom used by children was observed to be clean and in operating condition. The home has two pet dogs that are kept inaccessible to the children. Cleaning compounds, sharps, medicines, and other items which could pose a danger if readily available to children were stored inaccessible. Off Limit areas in the home are all three bedrooms and the garage. The backyard is fenced and used for outdoor activity. There were no bodies of water observed. Licensee stated that there were no weapons stored on the premises.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408)324-2151
LICENSING EVALUATOR NAME: Tuoc DoanTELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2020
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 4
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: MAES, TINA
FACILITY NUMBER: 434407945
VISIT DATE: 02/26/2020
NARRATIVE
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A fully charged fire extinguisher was observed. Carbon monoxide and Smoke Detectors were tested and proved to be functioning. Record shows that the last fire and disaster drills were conducted on 06/03/2019. Licensee stated that she does not provide transportation to day care children. Children's roster was reviewed and a copy was obtained. Children’s files were reviewed, which included records of Identification and Emergency Information, Consent for Emergency Medical Treatment, and Receipt for Parents' Rights Notice. Licensee and Assistant Provider Shellina Medeiros' files were reviewed, which included record for Criminal and Child Abuse Background Check Clearance, and immunization, required Training etc. Licensee's Pediatric CPR/1st Aid Certificate expires on 01/12/2021 and her AB1207 Mandated Reporter Certificate expires on 01/03/2021.

Licensee stated that she and her spouse are the only adults residing at the home. They have Clearances for TB, and Criminal Background and Child Abuse Index Checks. LPA reminded Licensee of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license, and who come in contact with or provide care and supervision to the children. For an initial violation, civil penalty amounts to $100.00 per person per day up to $500.00 per person. For a subsequent violation within a 12-month period, civil penalty amounts to $100.00 per person per day up to $3000.00 per person.

Licensee is encouraged to visit the Department’s website at www.cdss.ca.gov [Shortcut: www.ccld.ca.gov] to access resources for Providers, Regulations, Adoptions of new laws, pay annual fees etc.
Beginning January 1, 2019 AB2370 requires licensed homes to share information on the risks and effects of lead exposure with enrolling and re-enrolling families. LPA reviewed and provided a copy of the “Lead Poisoning Facts Information Flyer." Incidental Medical Services (IMS) policy was discussed. Licensee stated that she currently does not have any children in care who requires IMS. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) & link to Commonly Asked Questions and the ADA, available at:<http://www.ada.gov/childqanda.htm> .

In the areas that were evaluated regulatory violations were observed at the time of the inspection. Exit interview was conducted, where this report, the violations, plan of corrections, and appeal rights were reviewed with Licensee and a copy of the report was provided.
A NOTICE OF SITE VISIT WAS ISSUED AND MUST BE POSTED ON OR ADJACENT TO THE INTERIOR SIDE OF THE MAIN DOOR INTO THE FACILITY FOR 30 CONSECUTIVE DAYS
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408)324-2151
LICENSING EVALUATOR NAME: Tuoc DoanTELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2020
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: MAES, TINA
FACILITY NUMBER: 434407945
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/26/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/06/2020
Section Cited

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102418(g)(1) IMMUNIZATIONS. The licensee shall document each child's immunizations [...] and maintain such documentation for as long as the child is enrolled. This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family
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day care home.This requirement is not met as evidenced by: Per LPA's review of children's files, Licensee does not have documentation of Child 5's immunization record and Child 8 immunization record needs to be updated. This poses a potential risk to the health and safety of children in care.
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Type B
03/06/2020
Section Cited

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102417(g)(7) OPERATION OF A FAMILY CHILD CARE HOME. An emergency information card shall be maintained for each child and shall include the child's full name, telephone number [...] the parent's authorization for the licensee or registrant to consent to emergency medical care.
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This requirement is not met as evidenced by:
Per LPA's review of children's files, Licensee does not have authorization to consent to emergency medical care for Child 2, and Child 1 does not have an emergency information card. This poses a potential risk to the health and safety of 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: Sandy KnightTELEPHONE: (408)324-2151
LICENSING EVALUATOR NAME: Tuoc DoanTELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:
DATE: 02/26/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2020
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: MAES, TINA
FACILITY NUMBER: 434407945
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/26/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/06/2020
Section Cited

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102417(g)(9)(A) OPERATION OF A FAMILY CHILD CARE HOME. Each family child care home shall conduct fire drills and disaster drills at least once every six months. The licensee shall document the drills [...].
This requirement is not met as evidenced by:
Per LPA's review of facility's fire/disaster drill
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log, the last fire/disaster drill recorded to have been conducted was on 06/03/2019, which has been more than 6 months. This poses a potential risk to the health and safety of children in care.
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Type B
03/06/2020
Section Cited

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1597.622 HEALTH & SAFETY CODES. 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 [...], pertussis, and measles. [...] The family day care home shall maintain documentation of the required
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immunizations. This requirement is not met as evidenced by: Per LPA's review of files, Licensee and Assistant Provider Shellina Medeiros do not have documented proof that they are immune against Mealses and Pertussis. This poses a potential risk to the health and safety of 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: Sandy KnightTELEPHONE: (408)324-2151
LICENSING EVALUATOR NAME: Tuoc DoanTELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:
DATE: 02/26/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2020
LIC809 (FAS) - (06/04)
Page: 4 of 4