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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434410429
Report Date: 06/30/2022
Date Signed: 06/30/2022 11:58:04 AM


Document Has Been Signed on 06/30/2022 11:58 AM - 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:DE LA RIVA, SARAFACILITY NUMBER:
434410429
ADMINISTRATOR:DE LA RIVA, SARAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 483-0530
CITY:SAN JOSESTATE: CAZIP CODE:
95126
CAPACITY:14CENSUS: 6DATE:
06/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:01 AM
MET WITH:Sara De La RivaTIME COMPLETED:
12:28 PM
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Licensing Program Analysts (LPA) Pete Hernandez conducted an unannounced required 1 year inspection to the home today. LPA met with Licensee, Sara De La Riva, and explained the nature of today's visit. At the time of arrival the Licensee had 6 preschool aged children with her. Days and hours of operation are Monday – Friday from 8:00AM- 5:00PM. The Licensee states that she and her adult son, Roberto Zuniga, are the only adults that live in the home. Licensee’s and CPR/ First Aid expires on 05/1/2023.
LPA toured the indoor and outdoor areas of the home during today's visit. LPA observed the required posted documentation. LPA obtained and observed a current Child Care Facility Roster. The Licensee stated that she conducts Fire Drills every 6 months and the most recent was done 2/12/2022. The Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children. Off limit areas inside the home: entire upstairs (attic/ storage), two bedrooms and the laundry room. Off limit areas outside the home: left side of the home (fenced). LPA observed that the stairs to the attic/ storage area is barricaded by a locked door.
LPA observed a charged 2A10BC fire extinguisher. LPA observed operational smoke and carbon monoxide detectors and fire pull stations. LPA observed a barricaded fireplace and wall heater. The Licensee stated that there are no firearms in the home. Detergents, cleaning compounds are inaccessible to children.
A review of Staff records indicates that all persons that require a caregiver background check have received criminal record and child abuse index clearance or exemption. LPA informed Licensee of the applicable civil penalties for any adult who has not received fingerprint clearances, is not associated to the license and who comes in contact with or provides 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.
REPORT CONTINUED ON THE FOLLOWING PAGE (REPORT DATED 06/30/2022):
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Pietro HernandezTELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2022
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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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: DE LA RIVA, SARA
FACILITY NUMBER: 434410429
VISIT DATE: 06/30/2022
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CONTINUATION OF PREVIOUS PAGE (REPORT DATED 06/30/2022:
LPA reviewed eight (6) children’s files. All children have the required documentation.
The Licensee has completed the required Mandated Reporter training (AB1207). The Licensee state that she does not transport children via vehicle and she understands that children cannot be left in parked vehicles unattended at any time.
LPA provided the Community Care Licensing website www.ccld.ca.gov, so the licensee can obtain updated licensing information, new regulations and access forms. LPA also provided the e-mail address for the advocates in order to be added to the quarterly newsletter mailing list, childcareadvocatesprogram@dss.ca.gov.

LPA discussed the Individual Infant Care Plan LIC9227 with the Licensee.

Licensee has current Mandated Reporter Certificate. The Mandated Reporter expires 8/16/2023. 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.

Copy of children's roster was provided.

LPA discussed the requirements of AB 633 with the Applicant (or Licensee) and provided her the AB 633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and Applicant (Licensee) understands the requirements.

A deficiency is NOT being cited based on the LPA observation, interviews conducted, and record review in accordance with the California Code of Regulations, An exit interview was conducted, and Plan of Corrections were reviewed and developed with the licensee. A copy of this report were discussed and left with the Licensee, Sara De La Riva, whose signature on this form confirm receipt of these documents.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Pietro HernandezTELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022
LIC809 (FAS) - (06/04)
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