434409329-8-23-2019-07-CC-JTSE-BEMU9F-20190801152305

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434409329
Report Date: 08/01/2019
Date Signed: 08/23/2019 04:28:53 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:	MARTINEZ, ANA		FACILITY NUMBER:	434409329
ADMINISTRATOR:	ANA MARTINEZ		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 926-1903
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95127
CAPACITY:	14	CENSUS: 7	DATE:	08/01/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Ana Martinez		TIME COMPLETED:	03:30 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	LPAs Janet Tse and Susy Cervantes met with licensee Ana Martinez for an annual/random inspection. LPAs explained the nature of today's inspection to Licensee. Present were seven children with Licensee and her husband, who is also her assistant, in the home today. Adults living in the home are Licensee and her husband. Days and hours of operation are Monday to Friday, 6:00am to 6:00pm. LPAs toured the indoor and outdoor of the home. LPAs observed a blocked fireplace. Off limits indoor: one bedroom and the garage. There are no bodies of water. Licensee stated there is no firearms/weapons in the home. Sharp objects, medicines, poisons and cleaning supplies were inaccessible to the children. Outdoor area is fenced. LPAs observed the small storage shed has been removed and a large storage shed (10' x 10') has been added to the back yard. Exposed and external electrical wiring from the main house were connected to the storage shed. Circuit was also installed inside the storage shed. Licensing was not advised of the addition. LPAs reminded provider that she can only have 14 children according to her license. Fire extinguisher is size 3A40BC and filled. Smoke and carbon monoxide detectors are operable. Home is clean and orderly with heating and ventilation for safety and comfort. LPAs observed sufficient materials, toys, and play equipment for the day care children. Telephone is in working order. Children were supervised on the visit and LPAs went over substitute options. LPAs also discussed if Licensee transports children, they are never to be left in parked vehicles, and car seat laws shall be followed. A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 07/31/2019 was reviewed; and it indicates that all Facility staff or other individuals who require caregiver background checks have received criminal clearances and child abuse index clearances or exemptions. LPAs observed fire drill log which is to be done every 6 months. The last fire drill was done on 07/15/2019. Facility Evaluation Report dated 08/01/2019 to be continued on next page: (This is an amended report for the inspection conducted on 08/01/2019, delivered, and signed on 08/23/2019.)

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet Tse	TELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2019

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: MARTINEZ, ANA	FACILITY NUMBER: 434409329
	VISIT DATE: 08/01/2019

NARRATIVE

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Facility Evaluation Report dated 08/01/2019 to be continued from previous page:

LPAs obtained a copy of the current roster of the children. LPAs observed that Licensee and her husband have current Pediatric CPR/1^st Aid expiring 01/05/2021.

LPAs discussed the immediate civil penalties for Zero Tolerance of $500, and an ongoing $100 per day per violation continues until the violation(s) is corrected. LPAs also discussed the Healthy Beverage Act and AB633 requirements for A violations. LPAs observed Licensee's and her husband's immunization records were in file per SB792. 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.

Licensee was given a list of the current forms for childcare. Information on Safe Sleep Practice and Lead Poisoning was provided to Licensee. Licensee's and her husband's primary language is Spanish and are currently exempt from the Mandated Reporter AB1207 Compliant Child Care Training; however, Licensee and her husband completed the training on 11/11/2017 and 03/20/2018 respectively.

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

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet Tse	TELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2019

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: MARTINEZ, ANA	FACILITY NUMBER: 434409329
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/01/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/16/2019 Section Cited CCR 102416.3(a)	1 2 3 4 5 6 7	Alteration to Existing Buildings or Grounds. Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed. This requirement was not met as evidenced by: LPAs observed a large storage shed (10'	1 2 3 4 5 6 7	Licensee shall forward an updated facility sketch, both indoor and outdoor, to Licensing by 08/16/2019 due date. Once the facility sketch is received, fire clearance will be ordered by Licensing.
	8 9 10 11 12 13 14	x 10') has been added to the back yard. Exposed and external electrical wiring from the main house were connected to the storage shed. Circuit was also installed inside the storage shed. Licensing was not advised of the addition. This poses a potential risk to the Health, Safety, or Personal Rights of children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	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: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet Tse	TELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2019

LIC809 (FAS) - (06/04)

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