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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434409819
Report Date: 02/07/2020
Date Signed: 02/07/2020 03:15:35 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:LOPEZ, MARTHAFACILITY NUMBER:
434409819
ADMINISTRATOR:LOPEZ, MARTHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 608-4911
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY:14CENSUS: 4DATE:
02/07/2020
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Martha LopezTIME COMPLETED:
03:25 PM
NARRATIVE
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LPA Deanna Villagrana met with licensee Martha Lopez for an unannounced annual/random inspection. LPA explained the nature of today’s inspection to her. Present were licensee and four day care children. Days and hours of operation are Monday to Friday, 7:00am to 5:00pm. The adults that reside in the home are licensee and her husband.

A review of staff records on 01/27/2020 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee understands upon notice of the Department to remove an individual from the home, or to exclude an individual from the home, the licensee shall immediately remove the individual and prevents them from returning to the home or having contact with children in care.

LPA toured the indoor and outdoor areas of the home during today’s inspection. LPA observed that the home is clean and orderly, with heating and ventilation for safety and comfort of the children. LPA did not observe any stairs or wall heaters in the home. LPA observed safe and sufficient materials, toys, and play equipment for the day care children. All sharp objects, detergents, cleaning compounds, medications, poisons, and other similar items inside the home are stored inaccessible to children. LPA observed a fully charged 3A40BC fire extinguisher. LPA observed a working smoke detector and a working carbon monoxide detector. Licensee states there are no weapons/firearms in the home. Off limit areas indoor: master bedroom/bath, rented studio and kitchen that is barricaded off to the children. Children do pass through the kitchen to go outside to the backyard. There are no bodies of water. Backyard is fenced. Off limits outdoor: left and right side of home that is fenced off to children. Licensee states there are no animals in the home
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2020
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: LOPEZ, MARTHA
FACILITY NUMBER: 434409819
VISIT DATE: 02/07/2020
NARRATIVE
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LPA observed licensee has a current CPR and First Aid certification expiring 05/23/2020 and completed Mandated Reporter training on 02/28/2019. LPA observed a current roster of the children and a fire and disaster drill log which was last completed on 01/21/2020. LPA reviewed four children's files. Child 3 and 4 immunization need to be updated. Licensee states day care is not insured. LPA observed LIC282 in children's files LPA discussed SB792 Immunization Requirements and observed licensee has immunization records on file.


Supervision of children was discussed with 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 understands her capacity options and she understands that she cannot have more than 14 children in the home at any time. Licensee understands if she transports children via vehicle, children cannot be left in parked vehicles unattended at any time.

LPA discussed Zero Tolerance with $500 immediate civil penalty. An ongoing $100 per day per violation continues until the violation(s) is corrected. 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. LPA reminded the Licensee that effective January 1, 2019 Assembly Bill 2370 requires that all licensed homes to share information on the risks and effects of lead exposure with enrolling and re-enrolling families. LPA provided a copy of the “Lead Poisoning Facts Information Flyer” to the Licensee. Safe sleep information & handout was also discussed with the Licensee.

The following type B deficiency was cited on the attached page (809-D). Appeal rights were provided to the Licensees prior to the conclusion of today's inspection. Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction Due Date may result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.

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

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2020
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: LOPEZ, MARTHA
FACILITY NUMBER: 434409819
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/21/2020
Section Cited

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102418(g) Immunization. Licensee shall document and maintain each child’s immunizations as long as the child is enrolled.
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This requirement was not met as evidenced by Child 3 and 4 immunization need to be updated. This poses a potential risk Health, Safety Personal Rights risk to children in care.
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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 SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2020
LIC809 (FAS) - (06/04)
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