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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434409242
Report Date: 12/06/2019
Date Signed: 12/06/2019 03:28:06 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:HERNANDEZ CUEVAS, ANA B.FACILITY NUMBER:
434409242
ADMINISTRATOR:HERNANDEZ CUEVAS, ANA B.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 293-2323
CITY:SAN JOSESTATE: CAZIP CODE:
95122
CAPACITY:14CENSUS: 3DATE:
12/06/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Ana B. Hernandez CuevasTIME COMPLETED:
03:45 PM
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LPA Deanna Villagrana met with licensee Ana B. Hernandez Cuevas for an unannounced annual/random inspection. LPA explained the nature of today’s inspection to her. Present were licensee, licensee's mother, assistant and three day care children. Days and hours of operation are Monday to Friday, 5:00am to 5:30pm. The adults that reside in the home are licensee, her mother, two adult brothers and adult son.

A review of staff records on 11/19/2019 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. 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 a barricaded fireplace 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 combo smoke and carbon monoxide detector. Licensee states there are no weapons/firearms in the home. Off limit areas indoor: master bedroom/bath, two bedrooms and kitchen which is barricaded and inaccessible to children. There are no bodies of water. Backyard is fenced. The home is in a mobile home complex. Off limits outdoor: right side and backside of home that is fenced off to children. LPA observed three dogs in the home. Licensee states dogs are vaccinated.

LPA observed licensee CPR and First aid expires 06/22/2021. Licensee, her mother, and assistant have completed Mandated Reporter training. Licensee requested to not take training until available in Spanish because it was difficult to understand.

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

DATE: 12/06/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2019
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: HERNANDEZ CUEVAS, ANA B.
FACILITY NUMBER: 434409242
VISIT DATE: 12/06/2019
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LPA observed a current roster of the children and a fire and disaster drill log which was last completed 08/15/2019. LPA reviewed three children's files and observed all forms are completed and children have current immunization records. LPA observed day care is insured with DCI and expires 05/13/2020. LPA discussed SB792 Immunization Requirements and observed licensee, her mother and her assistant have current immunization's against pertussis, measles and influenza.

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. LPA discussed the requirements of AB633 to licensee and provided her the AB633 fact sheet and licensee understands the requirements. 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. Safe sleep information & handout was also discussed with the Licensee. Periodic information releases accessible by signing up at: www.myccl.ca.gov

No deficiency was cited.

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: 12/06/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2019
LIC809 (FAS) - (06/04)
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