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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434409791
Report Date: 07/12/2021
Date Signed: 07/12/2021 11:57:50 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:CEPILLO, BLAZIELFACILITY NUMBER:
434409791
ADMINISTRATOR:CEPILLO, BLAZIELFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 934-7110
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY:14CENSUS: 6DATE:
07/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Blaziel CepilloTIME COMPLETED:
12:15 PM
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On Monday, July 12, 2021 10:00 AM, Licensing Program Analyst (LPA) Manel Estoesta conducted an unannounced Required 1 year visit. LPA met with the Licensee Blaziel Cepillo. Present on this visit were the Licensee's Assisistant Kausar Ali, Licensee's teenage son and 10 preschool children and 1 infant. The facility currently operates from Monday to Friday 9am to 6pm.

LPA toured the home to conduct a Health and Safety Inspection. The home is neat and clean with heating and ventilation for safety and comfort.

The on limit areas (accessible to children in care) are the living room, dining room, day care room, kitchen, hallway bathroom and the backyard. The backyard play area is completely fenced.

The off limit areas are all bedrooms, master bathroom, the front yard and the garage which will be inaccessible to children in care by closed and or locked doors and or a fence with visual supervision.

There is a fireplace in the living and Licensee stated that the home is not using the fireplace.

There is a gate dividing the day care room and the dining room.

The designated isolation area for a child who becomes ill while in care is the living room.

There are ample age appropriate toys that appear to be safe and in good condition. There are no pools, hot tubs or any other bodies of water present during today's inspection. All hazardous materials and toxins are kept out of the reach of children and it was observed that there are no toxins or hazardous items accessible today. Licensee stated there are no firearms in the home.

SEE 809 C.....

SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Manel EstoestaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: CEPILLO, BLAZIEL
FACILITY NUMBER: 434409791
VISIT DATE: 07/12/2021
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Continuation....

The home has a fully charged Fire extinguisher. Carbon monoxide and smoke detectors were tested and proved to be functioning. Log shows that Disaster Drill was last conducted on January 2021 and today 07/12/2021. The Licensee stated that she does not transport children at this time but understands that children cannot be left alone, unattended in parked vehicles at any time.

Facility's roster of children who are provided care was reviewed and a copy was obtained. Children’s files were reviewed, which included records of receipt for Parents' Rights Notice, Identification and Emergency Information, Consent for Emergency Medical Treatment form, LIC 282 ( Licensee stated that she owns the home and she does not carry a Liability Child Care Insurance) and Immunization.

The Licensee's record shows as the following;
1. Pediatric CPR and Aid Certificate completed on 05/21/2021.
2. AB 1207 Mandated Reporter Training completed on 12/03/2020.

LPA Estoesta discussed, provided copies of New Safe Sleep Brochure, Lead Poisoning Facts Flyer and California Child Safety Seat Law, Guardian, Santa Clara County Resource and Referralto the licensee. For more information, please follow the links https://cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep, https://cdss.ca.gov/inforesources/child-care-licensing/water-testing-information and https://www.chp.ca.gov/Programs-Services/Programs/Child-Safety-Seats.

Individual Medical Services (IMS) policy was discussed. 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: https://www.ada.gov/childqanda.htm.

SEE 809 C....
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Manel EstoestaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: CEPILLO, BLAZIEL
FACILITY NUMBER: 434409791
VISIT DATE: 07/12/2021
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Continuation....

The licensee is reminded any structural changes to the home or additions to the child care facility must be reported to Community Care Licensing. Also, any adults moving into the home must be reported to Community Care Licensing prior to them moving in and all requirements must be met before the person lives in the facility.

Licensee is reminded that and associated to this facility prior all assistants, volunteers, frequent visitors, or adults living in the home, that are 18 years of age or older must be fingerprint cleared to being in the presence of children in care or an immediate civil penalty will be assessed from $100 to $3000 per person, per incident. Licensee was reminded of the responsibility as a mandated reporter. To file a complaint regarding a state licensed community care facility or child care facility, call Community Care Licensing Division Complaint Hotline 1-844-538-8766 or email letusno@dss.ca.gov.

Licensee is encouraged to visit the Department’s website to access resources for Providers, Title 22 Regulations, online option to pay Annual License fee, all forms can be downloaded, Child Care Resource & Referral Network (R&Rs) and more information at https://cdss.ca.gov/inforesources/child-care-licensing. This website link https://ccld.childcarevideos.org/ includes videos that explain licensing topics relevant to families and licensed child care providers.


Effective August 1, 2003 California Law requires Family Child Care Home licensees to report unusual incidents or injuries to children in care to child's parents and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624B). Incidents must be reported within 24 hours by phone, fax, or electronic mail.

For licensing updates, advised Licensee to email childcareadvocatesprogram@dss.ca.gov and request to be added to the email list. There are no deficiencies cited on this visit. This report shall remain on file for 3 years. A copy of the appeal rights was provided. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted.

SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Manel EstoestaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3