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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
434409981
Report Date:
11/01/2022
Date Signed:
11/01/2022 04:44:57 PM
Document Has Been Signed on
11/01/2022 04:44 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:
ENRIQUEZ, ROSA
FACILITY NUMBER:
434409981
ADMINISTRATOR:
ENRIQUEZ, ROSA
FACILITY TYPE:
810
ADDRESS:
TELEPHONE:
(408) 848-4515
CITY:
GILROY
STATE:
CA
ZIP CODE:
95020
CAPACITY:
14
CENSUS:
3
DATE:
11/01/2022
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
12:40 PM
MET WITH:
Rosa Enriquez
TIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Teodoro Trujillo and Samantha Yip conducted an unannounced Required- 1 Year inspection. LPAs met with Rosa Enriquez and explained the reason for the inspection. Present during today's inspection were Licensee, her spouse, and three children, whom one (1) was infant age.
License and facility sketch were observed to posted during today's inspection. LPAs discussed about required posting, such as notification of parent's rights. Licensee posted notification of parent's rights. The hours of operation are Monday through Friday 7AM to 5PM.
LPAs toured the inside and outside of home. The off-limit areas of the home are the entire upstairs. During inspection, LPAs observed that the Licensee was using the garage for the daycare children. Licensee does not have a permit to convert the garage for the daycare. LPAs explained that she needs to obtain a permit from the City of Gilroy to convert her garage for the daycare. Licensee will submit proof of permit and updated LIC 999 to obtain a updated fire clearance. LPAs observed that there were cleaning supplies, such as bottles of bleach, toilet bowl cleaners, all purpose cleaners, and laundry detergent, in the laundry room, the bathroom, and in the backyard, which is accessible to the children. Licensee moved cleaning supplies above the washer and dryer, which is inaccessible to children. LPAs also observed pruners in the laundry room and knives in the kitchen drawer, where it is accessible to children. There are toys for children. LPA observed that there
---------------------continues on 809 dated 11/01/2022 page 2------------------
SUPERVISOR'S NAME:
Mary Segura
TELEPHONE:
(408) 324-2152
LICENSING EVALUATOR NAME:
Teodoro Trujillo
TELEPHONE:
(408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE:
11/01/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/01/2022
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
13
Document Has Been Signed on
11/01/2022 04:44 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:
ENRIQUEZ, ROSA
FACILITY NUMBER:
434409981
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/01/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(4)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care. LPAs observed that there cleaning supplies in the children's restroom, laundry room, and in the backyard, which are accessible to children. There was a container of knvies in the kitchen drawer that was accessible to children.
POC Due Date:
11/02/2022
Plan of Correction
1
2
3
4
Deficiency was corrected. Licensee removed items and placed it where it was inaccessible.
Type A
Section Cited
CCR
102416.3(a)(1)
Alterations to Existing Building or Grounds
(a) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following: (1) Conversion of a garage (either attached or detached) into a "child care" room.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record reviews, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care. Licensee is using the garage for daycare children.
POC Due Date:
11/02/2022
Plan of Correction
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2
3
4
By POC 11/02/2022, Licensee will cease using the garage until a permit from the city is obtain; along with an updated fire clearance.
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:
Teodoro Trujillo
TELEPHONE:
(408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE:
11/01/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/01/2022
LIC809
(FAS) - (06/04)
Page:
2
of
13
Document Has Been Signed on
11/01/2022 04:44 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:
ENRIQUEZ, ROSA
FACILITY NUMBER:
434409981
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/01/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(1)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record reviews, the licensee did not comply with the section cited above in, which poses a potential health, safety or personal rights risk to persons in care. The fire extinguisher was last serviced on 02/01/2016
POC Due Date:
11/11/2022
Plan of Correction
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2
3
4
By POC 11/11/2022, Licensee will submit proof either fire extinguisher is serviced or an new fire extinguisher is purchased.
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above, which posesa potential health, safety or personal rights risk to persons in care. The last drill was conducted on 02/27/2020.
POC Due Date:
11/11/2022
Plan of Correction
1
2
3
4
By POC 11/11/2022, Licensee will submit proof of fire/disaster drill to Licensing.
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:
Teodoro Trujillo
TELEPHONE:
(408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE:
11/01/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/01/2022
LIC809
(FAS) - (06/04)
Page:
3
of
13
Document Has Been Signed on
11/01/2022 04:44 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:
ENRIQUEZ, ROSA
FACILITY NUMBER:
434409981
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/01/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on interview, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care. Licensee last completed training on 03/2019.
POC Due Date:
12/16/2022
Plan of Correction
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By POC 12/16/2022, Licensee will complete training and send proof to Licensing.
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 3 persons, which poses a potential health, safety or personal rights risk to persons in care. C-3 did not have form on file. C-1's form was not filled out completely.
POC Due Date:
11/11/2022
Plan of Correction
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2
3
4
By 11/11/2022, Licensee will have C-1 and C-3 parent's fill out form and send proof to Licensing.
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:
Teodoro Trujillo
TELEPHONE:
(408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE:
11/01/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/01/2022
LIC809
(FAS) - (06/04)
Page:
4
of
13
Document Has Been Signed on
11/01/2022 04:44 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:
ENRIQUEZ, ROSA
FACILITY NUMBER:
434409981
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/01/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 2 out of 3 persons, which poses a potential health, safety or personal rights risk to persons in care. C-1 and C-3 did not have immunization records on file.
POC Due Date:
11/18/2022
Plan of Correction
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3
4
By POC 11/18/2022, Licensee will obtain C-1 and C-3's immunization records and send proof to Licensing.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
Teodoro Trujillo
TELEPHONE:
(408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE:
11/01/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/01/2022
LIC809
(FAS) - (06/04)
Page:
5
of
13
Document Has Been Signed on
11/01/2022 04:44 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:
ENRIQUEZ, ROSA
FACILITY NUMBER:
434409981
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/01/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 2 persons, which poses a potential health, safety or personal rights risk to persons in care. C-3 did not have form on file.
POC Due Date:
11/11/2022
Plan of Correction
1
2
3
4
By POC 11/11/2022, Licensee will submit proof of completed form to Licensing.
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:
Teodoro Trujillo
TELEPHONE:
(408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE:
11/01/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/01/2022
LIC809
(FAS) - (06/04)
Page:
6
of
13
Document Has Been Signed on
11/01/2022 04:44 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:
ENRIQUEZ, ROSA
FACILITY NUMBER:
434409981
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/01/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
1
2
3
4
Based on interview, the licensee did not comply with the section cited above in 1 out of 1 persons, which poses a potential health, safety or personal rights risk to persons in care. C-1 did not have form on file.
POC Due Date:
11/11/2022
Plan of Correction
1
2
3
4
By POC 11/11/2022, Licensee will submit completed form to Licensing.
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, the licensee did not comply with the section cited above in 1 out of 1 persons, which poses a potential health, safety or personal rights risk to persons in care. Licensee checks infant while they are napping, but does not document it.
POC Due Date:
11/11/2022
Plan of Correction
1
2
3
4
By POC 11/11/2022, Licensee will document that 15 minute sleep check with the child's name, date, and time checked.
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:
Teodoro Trujillo
TELEPHONE:
(408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE:
11/01/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/01/2022
LIC809
(FAS) - (06/04)
Page:
7
of
13
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:
ENRIQUEZ, ROSA
FACILITY NUMBER:
434409981
VISIT DATE:
11/01/2022
NARRATIVE
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3
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5
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7
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----------------continuation of 809 dated 11/01/2022 page 1-----------------------
a baby jumper and baby bouncer in the home. Licensee understands that baby jumper and baby bouncers are not allowed in the home. There is a fire extinguisher, smoke detector, and carbon monoxide. LPAs discussed about ensuring that fire extinguishers are either serviced every year or she is obtaining a new fire extinguisher every year. Licensee stated that there are no weapons, such as firearms, in the home.
The backyard is used and is fenced. There were a bottle of Clorax cleaning supplies and bottle of cleaning supplies; along with bug removal and stain outside. LPA observed that there is wading pool on the side of the yard. LPAs discussed with Licensee to ensure that any water that collects in wading pool is dumped out. There were no other bodies of water observed during today's inspection.
LPAs observed that there was play mat attached to the side of the play yard and toys inside the play yard. Licensee removed play mat and toys from the play yard. Licensee stated that she checks infants every 15 minutes, but does not document it. LPAs provided Licensee with PIN 20-24. LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage 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.
-----------------continues on 809 dated 11/01/2022 page 3------------------------
SUPERVISOR'S NAME:
Mary Segura
TELEPHONE:
(408) 324-2152
LICENSING EVALUATOR NAME:
Teodoro Trujillo
TELEPHONE:
(408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE:
11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/01/2022
LIC809
(FAS) - (06/04)
Page:
10
of
13
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:
ENRIQUEZ, ROSA
FACILITY NUMBER:
434409981
VISIT DATE:
11/01/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
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23
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25
26
27
28
29
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32
--------------continuation of 809 dated 11/01/2022 page 2-----------------------
Licensee does not provide Incidental Medical Services (IMS). Incidental Medical Services (IMS) policy was discussed. For IMS information , see
PIN 22-02-CCP
.
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
A copy of the facility roster was obtained. Two (2) children's files were reviewed during today's inspection. The records reviewed include but not limited to immunization records and emergency contact. C-1 did not have LIC 9227: Individual Sleeping Plan, immunization records, and LIC 282 on file. LPA also observed that LIC 700 was not filled out completely. C-3 did not have forms on file.
Licensee's CPR/1st Aid expired on 02/2021. Licensee will send CPR/1st Aid card to Licensing upon completion. Licensee last completed the Mandated Reporter training on 03/26/2019. Licensee will submit certificate upon completion. Licensee was reminded that Mandated Reporter training requires renewal every two years.
The adults 18 and over living in the home are Licensee and her spouse. All adults have cleared fingerprints and TB test. 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.
As as result of this inspection, Type A citations, Type B citations, and technical violations were issued.
Exit interview conducted and report was reviewed with Licensee Rosa Enriquez. 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 Segura
TELEPHONE:
(408) 324-2152
LICENSING EVALUATOR NAME:
Teodoro Trujillo
TELEPHONE:
(408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE:
11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/01/2022
LIC809
(FAS) - (06/04)
Page:
11
of
13
Document Has Been Signed on
11/01/2022 04:44 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:
ENRIQUEZ, ROSA
FACILITY NUMBER:
434409981
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/01/2022
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(10)
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (10) A baby walker shall not be allowed on the premises of a family child care home in accordance with Health and Safety Code Sections 1596.846(b) and (c).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care. LPAs observed that there was a baby jumper and baby bouncer in the home.
POC Due Date:
11/11/2022
Plan of Correction
1
2
3
4
By POC 11/11/2022, Licensee submit written statement that baby jumper and baby walker was removed.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
Teodoro Trujillo
TELEPHONE:
(408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE:
11/01/2022
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/01/2022
LIC809
(FAS) - (06/04)
Page:
12
of
13
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:
ENRIQUEZ, ROSA
FACILITY NUMBER:
434409981
VISIT DATE:
11/01/2022
NARRATIVE
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---------------continuation of 809 dated 11/01/2022 page 4--------------------
LPAs Teodoro Trujilo and Samantha Yip informed Licensee Rosa Enriquez that this report dated 11/01/2022 documents two
Type A citation which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.
Also, LPAs informed the Licensee to provide a copy of this licensing report dated 11/01/2022
that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.
SUPERVISOR'S NAME:
Mary Segura
TELEPHONE:
(408) 324-2152
LICENSING EVALUATOR NAME:
Teodoro Trujillo
TELEPHONE:
(408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE:
11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/01/2022
LIC809
(FAS) - (06/04)
Page:
13
of
13