434409329-4-5-2023-07-CC-EBEN-CQLLHX-20230405084704

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434409329
Report Date: 03/30/2023
Date Signed: 04/05/2023 03:24:40 PM

Document Has Been Signed on 04/05/2023 03:24 PM - It Cannot Be Edited

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: 8	DATE:	03/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Ana Martinez		TIME COMPLETED:	01:15 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) Elizabeth Berumen met with Licensee, Ana Martinez for an unannounced Required – 1 year annual inspection. LPA was granted access to the home by the Licensee. LPA also observed Licensee's husband (Jorge Martinez) and eight day care children (3 infants & 5 preschoolers) in the home during today's inspection. Licensee was operating within her capacity and ratio requirements. LPA observed the required postings, including the facility license, near the front entrance to the home. Days and hours of operation are Monday - Friday from :600 AM to 6:00 PM. The adults currently residing in the home are: Licensee, Licensee's spouse (Jorge Martinez). There are no minor children residing in the home. LPA reviewed a current Child Care Facility Roster and Fire/Disaster drill log during today's inspection. The last fire/disaster drill was completed on 02/14/23. Licensee has day care insurance with Acord Insurance. Licensee and her spouse have current CPR and First Aid certifications (12/17/2024). Licensee has the required vaccines (MMR, Tdap, & flu) and is current with her Mandated Reporter Training for Child Care Workers. Both Ana and Jorge completed the Mandated Reporter training on 03/19/2022 and expires on 03/19/2024. LPA reviewed eight children's files the files were complete with the required forms, including the nap check sheets for children under 2 years of age. LPA reviewed Licensee and husband/assistant file and the files were complete with the required forms. Licensee states that a child will be isolated in the kitchen/dining room area if necessary due to illness or communicable disease. LPA toured the indoor and outdoor areas of the home during today's inspection. Licensee has a working telephone in the home. The home is clean, orderly, (including central heating/ventilation), and safe for the day care children. There are safe and age appropriate toys, play equipment, and materials for the children in the home. Off limit areas in the home are one bedroom (master bedroom). Off limit area in the backyard; right and left side yards. LPA observed two locked storage sheds that are off limits to children.

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Elizabeth Berumen	TELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

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: 03/30/2023

NARRATIVE

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LPA observed a fully charged 2A10BC fire extinguisher, working smoke/carbon monoxide detectors, and fenced backyard. The Licensee states that she does not have any weapons in the home. Licensee has a fish tank and a pet dog that is kept in off limit room. All detergents, cleaning compounds, medications, and other similar items are stored inaccessible to children. Licensee understands that all poisons are to be locked.

Licensee states that she provides meals (snacks, and lunch) to the day care children. Licensee understands that any food brought from home shall be labeled with each child's name and properly stored. Licensee understands that smoking is prohibited in the home.

Licensee states that she does not administer any medications to the day care children at this time. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. 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

Supervision of children was discussed with the 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 states that her husband transports children to and from school. Licensee understands that children shall not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Elizabeth Berumen	TELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

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: 03/30/2023

NARRATIVE

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LPA discussed the safe sleep regulations with the Licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed the Licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process

Exit interview conducted and report was reviewed with the Licensee, Ana Martinez. No deficiencies issued during today's inspection.

A Notice of Site Visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Elizabeth Berumen	TELEPHONE: (408) 318-1326
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

LIC809 (FAS) - (06/04)

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