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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434409097
Report Date: 07/25/2019
Date Signed: 07/25/2019 03:32:30 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:KURPIEWSKI, HELENFACILITY NUMBER:
434409097
ADMINISTRATOR:KURPIEWSKI, HELENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 472-4958
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY:14CENSUS: 8DATE:
07/25/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Ernestina & Mary KurpiewskiTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Stephanie Rangel met with for an unannounced annual/random inspection. The Licensee is currently not in the home today due a field trip with 5 other children (3 preschoolers and 2 school-age children). The Licensee gave sister in law Ernestina Kurpiewski consent to allow LPA to conduct the annual/random inspection today.

LPA observed 8 children in care including 1 infant and 7 preschool age children. Days and hours of operation are Monday - Friday from 7:30 AM to 5:30 PM. The adults that reside in the home are: Licensee, spouse, Licensee's brother, sister in law, Licensee's mother, father and Licensee's daughter. The Licensee's certifications for CPR and First Aid are current and expire in January 2020. Ernestina's CPR and First Aid certifications are current and expire in January 2020.

LPA viewed a current Child Care Facility Roster during the inspection. A Fire/Disaster drill log was observed. The last fire/disaster drill was completed on April 10, 2019. LPA reviewed 5 children's files and observed current and updated immunization records and the Family Child Care Home Notification of Parents' Rights forms (LIC 995A) in each file.

LPA toured the indoor and outdoor areas of the home during today's inspection. The home is safe for the daycare children. LPA did not observe any fireplaces or wall heaters in the day care areas. Off limit areas in the home: main house including living room, 2 bedrooms, laundry room, garage and the second floor (3 bedrooms & 2 bathrooms). The main house is enclosed by a door and children cannot go into it. The Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children.

LPA observed a fully charged 3A40BC fire extinguisher, working smoke/carbon monoxide detectors, fenced backyard, and no bodies of water. Ernestina states that there are no weapons in the home. There are four dogs in the home which are fully vaccinated. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children.


REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #2 - REPORT DATED 07/25/2019):
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Stephanie C RangelTELEPHONE: (408) 334-8556
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2019
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: KURPIEWSKI, HELEN
FACILITY NUMBER: 434409097
VISIT DATE: 07/25/2019
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CONTINUATION OF PREVIOUS PAGE (PAGE #1 - REPORT DATED 07/25/2019):

A review of staff records on July 27, 2019 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPA also reminded Ernestina 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. 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.


Licensee and staff that work directly with the children showed proof of immunization's for Measles (MMR), pertussis and flu vaccines). Licensee and her two staff showed proof of completion of mandated reporter training per AB 1207. The website for the online training is:http://www.mandatedreporterca.com/training/childcare.htm

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

IMS Policy to be submitted to CCL by 8/1/19

No deficiencies cited today.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE FRONT ENTRANCE TO THE HOME, AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS.

SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Stephanie C RangelTELEPHONE: (408) 334-8556
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2019
LIC809 (FAS) - (06/04)
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