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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434410062
Report Date: 12/15/2022
Date Signed: 12/15/2022 03:02:44 PM


Document Has Been Signed on 12/15/2022 03:02 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:RUIZ, ROSAFACILITY NUMBER:
434410062
ADMINISTRATOR:RUIZ, ROSAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 254-0595
CITY:SAN JOSESTATE: CAZIP CODE:
95116
CAPACITY:14CENSUS: 3DATE:
12/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:37 AM
MET WITH:Rosa RuizTIME COMPLETED:
03:15 PM
NARRATIVE
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On 12/15/2022 at 09:37 AM, Licensing Program Analyst (LPA) Teodoro Trujillo met with licensee, Rosa Ruiz, for an annual inspection and explained the reason for the visit to them. Present during today's visit were licensee and assistant Silvia, with 3 children: two preschool and one infant. Adults living in the home are licensee, her spouse and her adult daughter Crystal. Days and hours of operation are Monday through Friday 6:00 AM to 5:00 PM.

A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 12/06/2022 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 blocked fireplace, no wall heater, no stairs, and no bodies of water. Licensee stated there are no weapons. Licensee stated they have two cats and two birds and a gunnie pig. LPA observed a fully charged 4A60BC fire extinguisher. Carbon Monoxide detector and smoke detectors were operable. Sharp objects, medicines, poisons and cleaning supplies are inaccessible to the children and stored on top kitchen cabinet. Front yard is fenced. Off limit areas: three bedrooms (B1), B2 and B3, one bathroom, garage, and both gated right and left side yard, two locked plastic storage sheds, and two units.

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 they do transport 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 12/15/2022 pg. 1/2
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Teodoro TrujilloTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2022
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 6


Document Has Been Signed on 12/15/2022 03:02 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: RUIZ, ROSA
FACILITY NUMBER: 434410062

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2022

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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Based on observation, interview and record review, the licensee did not comply with the section cited above, licensee Rosa Ruiz completed on 10/20/2020 and assistant Silvia Ruiz completed on 4/29/2020, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/16/2023
Plan of Correction
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Licensee will submit proof of completion of Mandated Reporter Training to the San Jose Regional Office by close of business 01/16/2023.
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in assistant Silvia, CPR expired on 8/26/2022, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/16/2023
Plan of Correction
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Licensee will submit proof of current CPR card for assistant to the San Jose Regional Office by close of business 01/16/2023.
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: 12/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2022
LIC809 (FAS) - (06/04)
Page: 2 of 6


Document Has Been Signed on 12/15/2022 03:02 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: RUIZ, ROSA
FACILITY NUMBER: 434410062

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.3(a)(6)
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: (6) Any change from an area of the family child care home previously identified as "off limits" to an area where care and supervision will be provided to children in care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in Room 3 was converted for child care use, room 1 is now off limits, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/09/2023
Plan of Correction
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Applicant will submitt a written plan stating she has reviewed and understand the requirements to notify the department by close by business 01/09/2023.
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
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Based on observation and record review, the licensee did not comply with the section cited above in child 3 (c3) and c4 missing proof of immunizations which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/16/2023
Plan of Correction
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Licensee will submit copies of immunization cards for C3 and C4 by close of business to the San Jose Regional Office 01/16/2023.
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: 12/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2022
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 12/15/2022 03:02 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: RUIZ, ROSA
FACILITY NUMBER: 434410062

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)(1)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. (1) This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home.

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 in [ which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/16/2023
Plan of Correction
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Licensee shall forward a copy of the PM 286s of children #1, 2, 3, 4, 5 with current immunization records to LPA by 01/16/2023 due date.
Type B
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).

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 in child 1 (c1), c2, c3, and c4 files were missing LIC627 emergency information card, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/09/2023
Plan of Correction
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Licensee will submit copy of the emergency information card to the San Jose Regional Office by close of business 01/09/2023.
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: 12/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2022
LIC809 (FAS) - (06/04)
Page: 4 of 6


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: RUIZ, ROSA
FACILITY NUMBER: 434410062
VISIT DATE: 12/15/2022
NARRATIVE
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Continuation of report dated 03/23/2022 pg. 2/2
LPA observed a current roster of the children. LPA observed a fire and disaster drill log that was last conducted on 12/15/22. LPA reviewed 5 children’s files and observed all required documentation. Licensee was not compliance. Infant individual sleeping plan (LIC 9227) for each infant under 12 months was provided and discussed and a 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 10/20/20 and assistant Silvia completed on 4/29/2020. Licensee has Pediatric CPR/1st Aid expiring 06/05/2023 and Silvia expired on 8/26/2020. Needed documentation for SB 792 which requires immunization against Pertussis, Measles, and Influenza as well as TB testing is on file for licensee.
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. PIN 22-02-CCP was provided.

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.

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.

Type B deficiencies were cited during today's visit. Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction Due Date will 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, Rosa Ruiz. 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: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
LIC809 (FAS) - (06/04)
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