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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434408308
Report Date: 03/12/2020
Date Signed: 03/12/2020 03:44:37 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:ARREOLA, MARIAFACILITY NUMBER:
434408308
ADMINISTRATOR:ARREOLA, MARIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 272-4139
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY:14CENSUS: 8DATE:
03/12/2020
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Maria ArreolaTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dung Mac met with Licensees Maria Arreola at 12:10pm, for an unannounced annual inspection. LPA observed Licensee's minor son, Licensee's minor daughter, and eight day care children, of whom were two infants, two preschoolers, and four school-age during today's inspection.

Days and hours of operation are: Monday-Friday 6:00am-6:00pm. LPA toured the home both inside and out at 12:20pm. Off limit areas are all 3 bedrooms and garage. LPA observed the home is clean and safe for the day care children. LPA observed sufficient materials, toys, and play equipment for the day care children. Licensee stated that there are no weapons in the home.

LPA observed a fully charged fire extinguisher, working smoke detector/carbon monoxide. LPA observed cleaning products, toxic, medications were inaccessible to children. LPA observed fireplace is covered by a bookshelf to prevent access by children. Facility has 2 medium-sized dogs and are kept away during daycare hours. LPA observed fenced backyard and no bodies of water.

Licensee stated that she does not transport children. The last fire/disaster drill was conducted on 1/25/2020. LPA reminded Licensee that fire/disaster drill must be conducted every 6 months. Facility has a current Child Care Facility Roster. LPA reviewed Licensee and children's files at 1:00pm. Licensee did not have copies of immunization records and certificate of Mandated Reporter Training. Licensee's First Aid & CPR certifications expire 12/14/2021. LPA observed children's files were missing copies of Immunization Records and Notifications of Parent's Rights.

Adults who reside in the home are Licensee, Licensee spouse, and Licensee's daughter. They have Clearances for Tuberculosis, and Criminal Background and Child Abuse Index Checks. Licensees stated she does not have any children in care who requires administration of medication. IMS was discussed. ADA information line (800) 514-0301 (voice) and Commonly Asked Questionshttp://www.ada.gov/childquanda.htm. LPA provided a copy of the "Safe Sleep" and “Lead Poisoning Facts Information Flyer” Information to Licensee.

Type B deficiencies were cited today. An exit interview was conducted. Appeal Rights were given to Licensee. Notice of Site Visit must remain posted for 30 days.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Dung MacTELEPHONE: (408) 334-8550
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2020
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 3
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: ARREOLA, MARIA
FACILITY NUMBER: 434408308
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/13/2020
Section Cited

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IMMUNZATION REQUIREMENTS: 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 influenza, pertussis, and
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measles. This requirement is not met as evidenced by Licensee did not have records of measles and pertussis vaccinations which poses a potential health, safety, or personal rights risk to children in care.
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Type B
04/24/2020
Section Cited

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TRAINING FOR MANDATED REPORTER: On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child care provider, administrator, or employee of a licensed child day care facility
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shall complete the mandated reporter training. This requirement is not met as evidenced by Licensee was not aware of Mandated Reporter Training which poses health, safety, or personal rights risk to 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: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Dung MacTELEPHONE: (408) 334-8550
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2020
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: ARREOLA, MARIA
FACILITY NUMBER: 434408308
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/26/2020
Section Cited

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IMMUNIZATIONS: The licensee shall document each child's immunizations and shall maintain such documentation for as long as the child is enrolled. This requirement includes updating
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each child's PM 286 (6/95). This requirement is not met as evidenced by C1, C2, C6 did not have a copy of PM 286 which poses a potential health, safety, or personal rights risk to children in care.
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Type B
03/26/2020
Section Cited

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ADMISSION PROCEDURES: At the time of acceptance of each child into care, licensee shall provide the child's parent with a copy of Notification of Parents’ Rights-LIC 995A and request the child's
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parent to sign and date the bottom portion of the notice form. This requirement is not met as evidenced by there was no copy of LIC 995A in children's files which poses health, safety, or personal rights risk to 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: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Dung MacTELEPHONE: (408) 334-8550
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2020
LIC809 (FAS) - (06/04)
Page: 3 of 3