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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434409960
Report Date: 09/20/2022
Date Signed: 09/20/2022 02:57:19 PM


Document Has Been Signed on 09/20/2022 02:57 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:GARCIA, SILVIAFACILITY NUMBER:
434409960
ADMINISTRATOR:SILVIA GARCIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 806-7205
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY:14CENSUS: 2DATE:
09/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Silvia GarciaTIME COMPLETED:
03:15 PM
NARRATIVE
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On 09/20/2022 at 08:50 AM, Licensing Program Analyst (LPA) Teodoro Trujillo met with licensee, Silvia Garcia, for an annual inspection and explained the reason for the visit to them. Present during today's visit were licensee and assistant Gudalupe Gonzalez and adult daughter Stephanie Garcia and adult resident Evelia Ornelas with 2 children: one preschool and one infant. Adults living in the home are licensee and her husband Leonardo Garcia, two adult daughter, sister in law Evelia Ornelas and adult resident Denise Garcia. Days and hours of operation are Monday through Friday 6:00 AM to 6:00 PM.
A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 09/19/2022 was reviewed and it indicates that all Facility staff or other individuals who require caregiver background clearances have received criminal record and child abuse index clearances or exemptions. 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.

LPA inspected inside and outside of the home. LPA observed a barricaded fireplace, no wall heater, no stairs and no bodies of water. Licensee stated there are no weapons. Licensee states she has two vaccinated dogs. LPA observed a new and fully charged 3A40BC fire extinguisher. Carbon Monoxide detector and smoke detectors were operable. Sharp objects, medicines, poisons and cleaning supplies are inaccessible to the children. Off limit areas: Garage, 3 bedrooms and master bathroom. Off limit outside: enclosed left and far right side corner of back yard. Children were supervised during the visit and LPA went over substitute options and reminded licensee they could only have 14 children according to their license. Licensee stated she transports children, LPA reminded Licensee that children are never to be left in parked vehicles and must use appropriate car seats according to the child's age/weight/size. Continues on report dated 09/20/2022

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2022
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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Document Has Been Signed on 09/20/2022 02:57 PM - It Cannot Be Edited

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: GARCIA, SILVIA
FACILITY NUMBER: 434409960

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above, licensee had not started a safe sleep log for c1 and c3, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/21/2022
Plan of Correction
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Licensee will submit proof of safe sleep log for C1 and C2 to the San Jose Regional Office by close of business on 09/21/2022.
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above, C1 did not have LIC 9227 on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2022
Plan of Correction
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Licensee will provide a copy of completed LIC 9227 to the San Jose Regional Office by the close of business on 09/26/2022.

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: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/20/2022 02:57 PM - It Cannot Be Edited

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: GARCIA, SILVIA
FACILITY NUMBER: 434409960

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102369(b)(9)


This requirement is not met as evidenced by:
Evidence of a current tuberculosis clearance, not more than one year prior to or seven days after initial presence in the home, for any adult in the home during the time that children are under care.
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above, assistant Guadalupe Gonzalez and Evelia Ornelas did not have TB clearance on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2022
Plan of Correction
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Licensee will submit proof of TB clearance for Guadalupe and Evelia to the San Jose Regional Office by close business 10/04/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2022
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: GARCIA, SILVIA
FACILITY NUMBER: 434409960
VISIT DATE: 09/20/2022
NARRATIVE
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Continuation of report dated 09/20/2022 pg. 2/2
LPA observed a fire and disaster drill log that was last conducted on 06/28/2022. LPA reviewed 5 children’s files and observed Child (C1) and C2 were missing signature on LIC 995 and C1 file missing LIC 9227, C1 and C3 missing safe sleep log. The 15 minute check sleep log for infants under 24 months was discussed. LPA observed that the Licensee has Mandated Reporter training, training was completed on 01/1/2022, assistants Guadalupe Gonzlaez completed on 08/2/2021, Evelia Ornelas completed 9/19/2021 and Stephie Garcia completed on 9/6/2022. Licensee has Pediatric CPR/1st Aid expiring 05/2024, assistants Gudalupe expiring 5/2024, Stephanie 5/2024. Needed documentation for SB 792 which requires immunization against Pertussis, Measles, and Influenzais on file for licensee and assistants, TB clearance is missing for assistants Guadalupe and Evelia.

Incidental Medical Services (IMS) policy was discussed with the licensee. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The licensee is not providing IMS 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 discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed 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.

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022
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: GARCIA, SILVIA
FACILITY NUMBER: 434409960
VISIT DATE: 09/20/2022
NARRATIVE
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The following B deficiencies were cited on the attached page (809-D). Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction (POC) Due Date may result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.

Exit interview conducted and report was reviewed in Spanish with the licensee, Silvia Garcia. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022
LIC809 (FAS) - (06/04)
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