434410228-6-25-2021-07-CC-AMOS-C4BLTX-20210625090302

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434410228
Report Date: 06/23/2021
Date Signed: 06/25/2021 09:03:10 AM

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:	ROH, KAREN		FACILITY NUMBER:	434410228
ADMINISTRATOR:	ROH, KAREN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 247-0202
CITY:	SANTA CLARA	STATE: CA	ZIP CODE:	95051
CAPACITY:	14	CENSUS: 8	DATE:	06/23/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:50 PM
MET WITH:	Karen Roh		TIME COMPLETED:	05:05 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 6/17/21 at 2:50 pm: Licensing Program Analyst (LPA) Anna Morales conducted an unannounced Annual/Required Inspection ( Tool Kit One) . LPA met with Licensee, Karen Roh. Also present was one staff. There was ventilation for safety and comfort. Children were involved with age appropriate activities, under the supervision of the Licensee and staff. Days and hours of operation are Monday - Friday from 7:00 AM -6:00 PM. Adults over the age of 18 and residing in the home are the Licensee and son. All adults have Criminal Background Check Clearances, TB clearance and signed Criminal Record Statements LIC508 on file with Licensing Office. Licensee has a current CPR and First Aid card that expires on 12/13/22. Last disaster drill was conducted on 2/2021 The Licensee states that she lives in the home with her son. LPA's observed eight children, ( one infant under 12 months, and seven toddlers) The fireplace, located in the living room, is barricaded. Detergents, cleaning compounds, medications, and other hazardous items are inaccessible to the children in stored in locked cabinets, located in the kitchen area of the home. LPA did not observe any baby bouncers or baby walkers inside the home. LPA observed sufficient age appropriate play equipment for the children in the home. The home is clean, orderly, and safe for the children. Off limit areas outside the home: detached garage, right side section of the backyard, barricaded air conditioner unit (located in the back right side section of the backyard), and fenced garbage can area. There are no stairs inside the home. Observed mats for the children take naps in the activity room. The Licensee has a working telephone in the home. The home is clean, orderly, and safe for the day care children. LPA did not observe any wall heaters in the home. Page 1

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Anna Morales	TELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021

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 4

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: ROH, KAREN	FACILITY NUMBER: 434410228
	VISIT DATE: 06/23/2021

NARRATIVE

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LPA observed a fully charged 2A10BC fire extinguisher. There are working smoke detectors in the home. Carbon Monoxide detector was tested (observed green light) Licensee states there are not firearms of weapons in the home. LPA did not observe any bodies of water on the property. Licensee understands that all pools, spas, hot tubs, fish ponds, or similar bodies of water shall be covered or fenced as specified in title 22 regulations to be inaccessible to children.

LPA's reviewed four of the Emergency Information Cards(LIC700) which were complete and updated. LPA reminded Licensee of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who comes in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12-month period.

Incidental Medical Services (IMS) policy was discussed. The Licensee stated that she currently does not have any children in care who requires IMS. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department.

The last Mandated Reporter Certificate for licensee was reviewed with date taken on 6/18/2018. LPA discussed Senate Bill 792, Assembly Bill (AB) 1207 (Mandated Child Abuse Reporting Training) which is required training that began on January 1, 2018 and requires renewal every two years, AB 633 was discussed with applicant Licensing forms, Title 22 regulations, can be obtained through the internet at www.ccld.ca.gov. Mandated Reported Training can be accessed atwww.mandatedreporterca.com.

Website for resource information: http://www.cdss.ca.gov/inforesources/Community-Care/Self-Assessment-Guides-and-Key-Indicator-Tools/Quarterly-Updates
(page 2)

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Anna Morales	TELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: ROH, KAREN	FACILITY NUMBER: 434410228
	VISIT DATE: 06/23/2021

NARRATIVE

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Continued from 809c page 2.

One type B deficiency is being cited based on the LPAs observations, interviews conducted and records reviewed in accordance with the California Code of Regulations Title 22.

LPA conducted an exit interview with the Licensee . LPA discussed and left a copy of Pin 20-24-CCP, RECENTLY APPROVED SAFE SLEEP REGULATIONS IN EFFECT. Discussed that all INFANTS UP TO 12 MONTHS OF AGE MUST HAVE AN INDIVIDUAL INFANT SLEEPING PLAN (LIC9227) OF FILE, WHICH WILL DOCUMENT THE INFANTS SLEEPING HABITS, USUAL SLEEPING ENVIRONMENT, AND THE INFANT ROLLING ABILITIES.

A NOTICE OF SITE VISIT WAS ISSUED, AND TO BE POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Anna Morales	TELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: ROH, KAREN	FACILITY NUMBER: 434410228
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/23/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/07/2021 Section Cited	1 2 3 4 5 6 7	MANDATED REPORTER TRAINING. [...] a person who, on January 1, 2018, is a licensed child care provider [...] shall complete the mandated reporter training provided [...] and shall complete renewal mandated reporter training every two years
	8 9 10 11 12 13 14	LPA observed that Licensee and her assistant have not completed the Mandated Reporter Training (Licensee, 6/18/2018,assistant 6/27/18.This poses a potential risk to children's health and safety of children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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: Sandy Knight	TELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Anna Morales	TELEPHONE: (408) 334-8325
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021

LIC809 (FAS) - (06/04)

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