434409640-8-14-2019-07-CC-AALZ-BF2TDA-20190814143800

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434409640
Report Date: 08/14/2019
Date Signed: 08/14/2019 02:38:10 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, LORENA		FACILITY NUMBER:	434409640
ADMINISTRATOR:	LORENA HERNANDEZ		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 334-9528
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY:	14	CENSUS: 9	DATE:	08/14/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Hernandez, Lorena		TIME COMPLETED:	02:45 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) Almaraz, Araceli conducted an annual random inspection. LPA met with Licensee, Hernandez, Lorena and explained the nature of today's inspection. Present during the inspection was the licensee Hernandez, Lorena and son/assistant Hernandez, Brian. There were nine children present, three infants and six toddlers. The hours of operation of the day-care are 6 AM to 5:30 PM, Monday through Friday. There are three adults residing in the home; Licensee, spouse Hernandez, Gustavo, son/assistant and one minor daughter. Licensees mother Uribe De Velzasco, Josefina is an occasional visitor to the home. Licensee has CPR and First Aid, which has an expiration date of 01/2021. LPA observed that the Licensee has record of MMR & Tdap vaccinations as well the flu vaccine. LPA observed assistant did not have record of immunization's. Licensee completed Mandated Reporter Training on 01/2019, licensee understands training is to be completed every two years. LPA reviewed nine children's files and observed current and updated immunization records and the Family Child Care Home Notification of Parents' Rights forms (LIC 995A) in each file. LPA observed a current roster, a current fire disaster/earthquake drills last log 05/2019. LPA observed a working smoke/carbon monoxide detector, 2A10BC fire extinguisher that is not fully charged. LPA observed no bodies of water, there is a fountain in the backyard that is kept upside down to prevent water from collecting. LPA did not observe any heaters in the home. LPA observed a barricaded fireplace. LPA inspected the indoor areas of the home today. Off limit areas in the home are as follows; Master bedroom/bathroom and three bedrooms. Medication, cleaning products and similar items are stored inaccessible to children. Poisons must be locked. Licensee states that there are no weapons in the home. Licensee has no pets. Licensee has no day care insurance. Report Continued on Page 2*****

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Araceli Almaraz	TELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2019

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: HERNANDEZ, LORENA	FACILITY NUMBER: 434409640
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/14/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/04/2019 Section Cited CCR 102417(g)(4)	1 2 3 4 5 6 7	Operation of a Family Child Care Home: Poisons, detergents, cleaning compounds, medicines...other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children. This requirement was not met as evidenced by LPA observed licensee failed to meet this requirement. Off limits storage shed not locked with items such as rubbing alcohol accessible.. This poses a potential risk to the health and safety of the children in care.	1 2 3 4 5 6 7	Liceensee will submit a signed statement that regulation 102417(g)(4) is understood and storage shed will be locked during day care hours. Licensee will submit this on or before 09/04/2019 via fax, mail, email attachment and/or text photo. Licensee locked door during visit.
Type B 09/04/2019 Section Cited CCR 102417(g)(4)	1 2 3 4 5 6 7	Operation of a Family Child Care Home: Poisons, detergents, cleaning compounds, medicines...other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children. This requirement was not met as evidenced by LPA observed licensee failed to meet this requirement. Off limits garage door open with items such as cleaning compunds accessible.. This poses a potential risk to the health and safety of the children in care.	1 2 3 4 5 6 7	Liceensee will submit a signed statement to LPA that regulation 102417(g)(4) is understood and garage door will be locked preventing access to outside during day care hours. Licensee will submit this on or before 09/04/2019 via fax, mail, email attachment and/or text photo. Licensee locked door during visit. Licensee will get a safety knob for the door that leads to the garage from kitchen and send photos also.
Type B 09/04/2019 Section Cited CCR 102417(g)	1 2 3 4 5 6 7	Operation of a Family Child Care Home :The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not be limited to.. This requirement was not met as evidenced by LPA obseved licensee failed to meet this requirement by not having air conditioning unit barricaded in an accessible area. This poses a potential risk to the health and safety of the children in care,	1 2 3 4 5 6 7	Licensee will barricade air conditioning unit and send proof of barricade on or before 09/04/2019 to LPA via mail, fax,email and/or text photo.
Type B 09/04/2019 Section Cited CCR 102417(g)	1 2 3 4 5 6 7	Operation of a Family Child Care Home The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not be limited to... This requirement was not met as evidenced by LPA obseved licensee failed to meet this requirement by not having riight, left and area behind storage accessible with items that could pose a risk in those areas. This poses a potential risk to the health and safety of the children in care,	1 2 3 4 5 6 7	Licensee will barricade acess to left, and right side of the yard. Licensee will also close off tthe area behind the strorae shed that leads to the left side of the yard. Licensee send proof of barricade and/or gate on or before 09/04/2019 to LPA via mail, fax,email and/or text photo. LIcensee put a tempory barricade during visit on each side. Supervision and temporary barricades will prevent access until it is fully gated and/or barricaded.

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: Araceli Almaraz	TELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2019

LIC809 (FAS) - (06/04)

Page: 4 of 5

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, LORENA	FACILITY NUMBER: 434409640
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/14/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/04/2019 Section Cited CCR 102417(g)(1)	1 2 3 4 5 6 7	Operation of a Family Child Care Home: The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshal, pursuant to Fire Marshal Section of the Health and Safety Code. This requirement was not met as evidenced by LPA observed licensee failed to meet this requirement. LPA observed the fire extinguisher was not fully charged, last serviced 03/2018. This poses a potential risk to the health and safety of the children.	1 2 3 4 5 6 7	Licensee will replace or refill extinguisher and submit proof with picture of charging zone and reciept if purchased to LPA on or before 09/04/2019 via fax, mail, email and/or text photo.
Type B 09/04/2019 Section Cited HSC 1597.622(a)(1)	1 2 3 4 5 6 7	Health and Safety Code: Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. This requirement was not met as evidenced by LPA observed licensee failed to meet this requirement by not having record of immunizations for assistant. This poses a potential risk to the health and safety of the children.	1 2 3 4 5 6 7	Licensee will submit proof of immunzations for assistant to LPA on or before 09/04/2019 via fax, mail, email and/or text photo,.
	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: Araceli Almaraz	TELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2019

LIC809 (FAS) - (06/04)

Page: 5 of 5

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, LORENA	FACILITY NUMBER: 434409640
	VISIT DATE: 08/14/2019

NARRATIVE

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A review of staff records on 08/13/2019 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. 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. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12-month period.

Website for provider resources: http://www.cdss.ca.gov/inforesources/Community-Care/Self-Assessment-Guides-and-Key-Indicator-Tools/Quarterly-Updates

LPA conducted an exit interview with the Licensee and advised the licensee of the pending Department regulation update re: safe sleep for infant children. LPA referred the Licensee to the Department website: www.ccld.ca.gov for additional information. LPA discussed the requirements of AB633 to Licensee.

The following Type B deficiencies noted on the attached page (809-D): Appeal rights provided to the Licensee prior to the conclusion of today's inspection.

NOTICE OF SITE VISIT WAS ISSUED, AND MUST BE POSTED FOR 30 DAYS.

Final Page of Report Continued from Page 2*****

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Araceli Almaraz	TELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2019

LIC809 (FAS) - (06/04)

Page: 3 of 5

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, LORENA	FACILITY NUMBER: 434409640
	VISIT DATE: 08/14/2019

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LPA inspected the outdoor areas of the home today. Off limit areas outside the home are as follows: Storage shed that has been converted into a bedroom. LPA observed the shed was not locked which had items accessible that could pose a potential risk the the children in care. LPA observed the left side of the back yard is currently not safety compliant. LPA observed an air conditioning unit that has direct access to the children in care and other items that could pose a potential risk to the children in care. LPA observed the right side of the back yard is currently not safety compliant. The right side of the yard had items that could pose a potential risk to the children in care. LPA observed the door leading to the off limits garage was open. LPA observed items that could pose a potential risk to the children in care. LPA observed licensee close the door with access to the garage and lock the storage shed during inspection. LPA observed licensee temporarily barricade the right side of the yard with a gate and the left side of the yard with a bench and plants. Licensee states supervision will be used in addition to these deterrents. LPA and licensee discussed the air conditioning unit other items in the back yard that has direct access to the children in care. Licensee understands the potential risks and would like to minimize any risks it may cause. The front yard is safety compliant and backyard is fully fenced.

Supervision of the children was discussed; the Licensee understands a cleared adult must be present in the home during day care hours. Licensees understand that the children must be supervised at all times. The Licensee understands the capacity options and ratio requirements. Licensee understands not to leave children in the car unattended. The Licensee states that there is no transporting of children currently.

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

Report Continued on Page 3*****

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Araceli Almaraz	TELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2019

LIC809 (FAS) - (06/04)

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