434409299-10-28-2019-07-CC-DMAC-BHDQKN-20191028121437

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434409299
Report Date: 10/28/2019
Date Signed: 10/28/2019 12:14:46 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:	ORTIZ-ACEVEDO, ROSE		FACILITY NUMBER:	434409299
ADMINISTRATOR:	ORTIZ-ACEVEDO, ROSE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	4083136372
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95122
CAPACITY:	14	CENSUS: 7	DATE:	10/28/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Rose Ortiz-Acevedo		TIME COMPLETED:	12:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Dung Mac and Licensing Program Manager (LPM), Diana Stephenson met with Licensee Rose Ortiz-Acevedo for an unannounced annual inspection. Present were Licensee, Licensee's spouse, Manuel Salas, and seven day care children, of whom were four infants and three preschoolers. Days and hours of operation are: Monday-Friday 6:00am-7:00pm. LPM and LPA toured the home both inside and out. The facility is a two-story house. Off-limit areas are Licensee's mother's bedroom and all upstairs which consist of two bedrooms and master bedroom. LPM and LPA did not observe any bodies of water. Licensee states that there are no firearms in the home. Detergents, cleaning products, medications, hazardous and other toxic materials are inaccessible to children. LPM and LPA observed a fully charged fire extinguisher. Smoke and Carbon Monoxide detectors were tested and proved to be functioning. The home is clean, orderly, and safe for the day care children. LPM and LPA observed sufficient materials, toys, and play equipment for the day care children. LPM and LPA observed that the wall heater is screened to prevent access by children. The second floor is barricaded by a gate by the stairs to prevent access by children. Licensee stated that she transports children so licensee was reminded that children are not left in parked vehicle. LPM and LPA reviewed the Child Care Facility Roster. The last fire/disaster drill was conducted on 7/15/19. Seven children's files were reviewed and Affidavits Regarding Liability Insurance (LIC 282) are not on file. Licensee and Licensee's spouse files were reviewed. Licensee's Pediatric CPR & First Aid certification expires 7/14/20. REPORT CONTINUED ON PAGE # 2

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Dung Mac	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2019

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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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: ORTIZ-ACEVEDO, ROSE	FACILITY NUMBER: 434409299
	VISIT DATE: 10/28/2019

NARRATIVE

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Licensee and spouse maintain records of immunization. Licensee's Mandated Report training expires 10/12/20. LPM and LPA reminded Licensee that the Mandated Reporter Training needs to be renewed every two years.

A review of records on 10/28/19 shows that all staff and other adults who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

Adults who reside in the home are Licensee, Licensee's spouse, and Licensee's mother. They have Clearances for Tuberculosis, and Criminal Background and Child Abuse Index Checks. LPM and 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.

Licensee stated she does not have any children in care who requires administration of medication. The facility is not providing Incidental Medical Services at this time. IMS was discussed. The following US Department of Justice resource was provided: http://www.ada.gov/childqanda.htm.

LPM and LPA provided a copy of the “Lead Poisoning Facts Information Flyer” and Safe Sleep Information to Licensee.

Licensee was encouraged to frequently visit our website at www.ccld.ca.gov for licensing updates and regulations.
Licensee was reminded that Mandated Reporter for all staff is required. The Mandated Reporter Training website is http://mandatedreporterca.com.

A Type B citation was cited today and must be corrected by due date. An exit interview was conducted. The appeal rights and Notice of Site Visit were given and must remain posted for 30 days.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Dung Mac	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2019

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: ORTIZ-ACEVEDO, ROSE	FACILITY NUMBER: 434409299
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/28/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/08/2019 Section Cited	1 2 3 4 5 6 7	OPERATION OF A FAMILY DAY CARE HOME: The licensee shall maintain affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.
	8 9 10 11 12 13 14	This requirement is not met as evidence by. Based on the review of children's file, there is no copy of LIC 282 on file which poses a potential Health, Safety, or Personal Rights risk to children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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 Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Dung Mac	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2019

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2019

LIC809 (FAS) - (06/04)

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