Community Care Licensing

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: 6	DATE:	05/17/2023
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	10:55 AM
MET WITH:	Lorena Hernandez		TIME COMPLETED:	01:00 PM

SUPERVISOR'S NAME: Diana Stephenson TELEPHONE: (408) 324-2128 LICENSING EVALUATOR NAME: Janette Cruz TELEPHONE: (408) 334-8312 LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2023

Document Has Been Signed on 05/17/2023 01:25 PM - It Cannot Be Edited

FACILITY NAME: HERNANDEZ, LORENA	FACILITY NUMBER: 434409640
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/17/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/24/2023 Section Cited CCR 102425(b)	1 2 3 4 5 6 7	102425 Infant Safe Sleep (b) Cribs or play yards shall be free from all loose articles and objects. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee immediately removed the blanket and other objects from the infant inside the crib. Licensee will review Infant Safe Sleep Regulations and submit a statement of understanding regarding ensuring cribs or play yards shall be free from loose articles at all times.
	8 9 10 11 12 13 14	Based on observation, Licensee did not comply with the section cited above. LPA and LPM observed an infant in care (C1) was swaddled, had blanket on also had other pillows and toys during naptime inside the infant play yard which posed a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
Type B 05/24/2023 Section Cited CCR102425(j)(2D)	1 2 3 4 5 6 7	102425 Infant Safe Sleep (j) The provider shall supervise infants while they are sleeping and adhere to the following requirements: (2)The provider shall check and document the following: (D) Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: a. Date. b. Infant’s name. c. Time of each 15-minute check. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee will submit Infant safe sleep checks every 15-minutes. LIcensee will review Infant Safe Sleep Regulations and submit a statement of understanding regarding infant's file to be maintained regarding supervision.
	8 9 10 11 12 13 14	Based on observation, Licensee did not comply with the section cited above. Licensee did not maintain documentation of sleep check for C1 which posed a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14

SUPERVISOR'S NAME: Diana Stephenson TELEPHONE: (408) 324-2128 LICENSING EVALUATOR NAME: Janette Cruz TELEPHONE: (408) 334-8312 LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2023

Document Has Been Signed on 05/17/2023 01:25 PM - It Cannot Be Edited

FACILITY NAME: HERNANDEZ, LORENA	FACILITY NUMBER: 434409640
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/17/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/24/2023 Section Cited CCR 102425(c)(1)(2)	1 2 3 4 5 6 7	102425 Infant Safe Sleep (c) An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 month of age the provider has in care and maintained at the facility in the infant’s file. (1) This plan shall be signed and dated by the infant’s authorized representative. (2) The Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be maintained in the infant’s file and shall be available to the Department for review. This requirement was not met as evidenced by	1 2 3 4 5 6 7	Licensee will review Infant Safe Sleep Regulations and submit LIC 9227 for child C1 and a statement of understanding regarding infant's file to be maintained regarding supervision.
	8 9 10 11 12 13 14	Based on observation, Licensee did not comply with the section cited above. Licensee did not maintain LIC9227 Infant Sleeping Plan for C1 which posed a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
Type B 05/24/2023 Section Cited CCR102417(8)(A)	1 2 3 4 5 6 7	102417 Operation of a Family Child Care Home(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841. (A)Each child day care facility shall maintain a current roster of children who are provided care in the facility. The roster shall include the name, address, and daytime telephone number of the child's parent or guardian, and the name and telephone number of the child's physician. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee will submit to LPA Cruz an updated and completed child care roster by POC due date. Licensee will also submit a statement of understanding that a current child care roster will be maintained and available to the licensing agency upon request
	8 9 10 11 12 13 14	Based on observation, Licensee did not comply with the section cited above. Licensee did not maintain a current child care roster with complete information of children in care which posed a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14

SUPERVISOR'S NAME: Diana Stephenson TELEPHONE: (408) 324-2128 LICENSING EVALUATOR NAME: Janette Cruz TELEPHONE: (408) 334-8312 LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2023