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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434409237
Report Date: 02/26/2020
Date Signed: 02/26/2020 03:55:36 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:CAMACHO, EVAFACILITY NUMBER:
434409237
ADMINISTRATOR:EVA CAMACHOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 667-6050
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY:14CENSUS: 2DATE:
02/26/2020
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Eva CamachoTIME COMPLETED:
04:05 PM
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Upon arrival LPA Deanna Villagrana met with a lady at the front door who later was identified as Alejandra Medina. Alejandra stated LPA had to go around to the back of the home to enter were licensee Eva Camacho was. LPA explained the nature of today’s inspection to her. Present were licensee, licensee's mother and two day care children including one foster child. Licensee states Alejandra, Alejandra's husband and adult son lives in the upstairs part of the home. Licensee's mother was visiting and did not interact with children. LPA observed at 1:31pm a child restrained and sleeping in a car seat inside a bedroom that is on limits. Licensee stated she was leaving to get her mother's medicine before picking up child from school and that was the reason child was in the car seat. LPA asked what time licensee was leaving. Licensee stated she could wait 20 minutes more before leaving to pick up child. LPA asked licensee to remove child from car seat until it was closer to her leaving. Licensee removed child at 1:38pm. Days and hours of operation are Monday to Friday, 6:00am to 6:00pm. The adults that reside in the home are licensee, her husband, three adult daughters, 12-year-old daughter and one year old foster child.

A review of staff records on 002/25/2020 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee understands upon notice of the Department to remove an individual from the home, or to exclude an individual from the home, the licensee shall immediately remove the individual and prevents them from returning to the home or having contact with children in care.

LPA toured the indoor and outdoor areas of the home during today’s inspection. LPA observed that the home is clean and orderly, with heating and ventilation for safety and comfort of the children. LPA observed stairs were barricaded by a door in the home. LPA observed safe and sufficient materials, toys, and play equipment for the day care children. All sharp objects, detergents, cleaning compounds, medications, poisons, and other similar items inside the home are stored inaccessible to children. LPA observed a fully charged 3A40BC fire extinguisher. LPA observed a working smoke detector and a working carbon monoxide
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
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 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: CAMACHO, EVA
FACILITY NUMBER: 434409237
VISIT DATE: 02/26/2020
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detector. Licensee states there are no weapons/firearms in the home. Off limit areas indoor: two bedrooms and entire upstairs which consists of three bedrooms, one bathroom, a living room, a kitchen, and a dining room. There is a swimming pool that is barricaded with a 5ft metal fence. Licensee states they will be using the pool during summertime and understands children must be supervised at all times. Backyard is fenced. Off limits outdoor: locked storage and right side of home that is fenced off to children. LPA observed two dogs in the home. Licensee states dogs are vaccinated.

LPA observed licensee has current CPR and First Aid certification expiring 01/19/2021. LPA observed a current roster of the children. LPA observed a fire and disaster drill log which was last completed on 01/10/2020. LPA reviewed two children's files and observed all forms are completed and children have current immunization records. Licensee states day care is not insured. LPA observed LIC282 in each child's file. Licensee left the home at 2:00pm to pick up a child from school. LPA completed report in rental car. Licensee returned at 3:00pm with another child and without her mother.


Supervision of children was discussed with licensee and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. Licensee understands her capacity options and she understands that she cannot have more than 14 children in the home at any time. Licensee understands if she transports children via vehicle, children cannot be left in parked vehicles unattended at any time.

LPA discussed Zero Tolerance with $500 immediate civil penalty. An ongoing $100 per day per violation continues until the violation(s) is corrected. Incidental Medical Services were discussed with the licensee. The licensee is not providing IMS (Incidental Medical Services) at this time. Licensee will submit an updated plan of operation if in the future they provide any IMS services to a child in care.

LPA reminded the Licensee that effective January 1, 2019 Assembly Bill 2370 requires that all licensed homes to share information on the risks and effects of lead exposure with enrolling and re-enrolling families. LPA provided a copy of the “Lead Poisoning Facts Information Flyer” to the Licensee. LPA advised the Applicant of the pending Department regulation update regarding safe sleep for infant children. LPA referred the Applicant to the Department website: www.ccld.ca.gov for additional information and provided licensee with a "Safe Sleep" handout.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
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 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: CAMACHO, EVA
FACILITY NUMBER: 434409237
VISIT DATE: 02/26/2020
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No deficiency was cited during visit. A copy of this report and appeal rights were discussed and left with licensee Eva Camacho, whose signature on this form confirm receipt of these documents.

Notice of site visit was issued and must be posted for 30 days.

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
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)
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