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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434410468
Report Date: 01/22/2020
Date Signed: 01/22/2020 03:14:44 PM

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:GAETA, ABELICIAFACILITY NUMBER:
434410468
ADMINISTRATOR:GAETA, ABELICIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 842-8076
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY:14CENSUS: 9DATE:
01/22/2020
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Abelicia GaetaTIME COMPLETED:
03:25 PM
NARRATIVE
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LPA Deanna Villagrana met with licensee Abelicia Gaeta for an unannounced annual/random inspection. LPA explained the nature of today’s inspection to her. Present were licensee, licensee's husband, assistant and 10 day care children. Days and hours of operation are Monday to Friday, 6:00am to 6:00pm. The adults that reside in the home are licensee, her husband, and two adult sons.

A review of staff records on 01/21/2020 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee understands upon notice of the Department to remove an individual from the home, or to exclude an individual from the home, the licensee shall immediately remove the individual and prevents them from returning to the home or having contact with children in care.

LPA toured the indoor and outdoor areas of the home during today’s inspection. LPA observed that the home is clean and orderly, with heating and ventilation for safety and comfort of the children. LPA observed a child sleeping in an off limits bedroom. LPA inspected room to ensure room can be place on limits. Room was acceptable for use. LPA observed a 3 month old infant in on limits room after being at facility for over and hour and a half. Licensee did not inform LPA of infant. Licensee did not check on child within the hour and a half LPA was present. LPA did not observe a fireplace, stairs or wall heater in the home. LPA observed safe and sufficient materials, toys, and play equipment for the day care children. LPA observed shampoo and conditioner accessible to children in shower of bathroom used by children. LPA observed a fully charged 3A40BC fire extinguisher. LPA observed a combo smoke and carbon monoxide detector not working in the home. Licensee states there are no weapons/firearms in the home. Off limit areas indoor: master bedroom/bath, one bathroom and attached garage. There are no bodies of water. Backyard is fenced. Off limits outdoor: left side of home that is fenced off to children and back studio. Licensee states there are no animals in the home.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2020
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 7
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: GAETA, ABELICIA
FACILITY NUMBER: 434410468
VISIT DATE: 01/22/2020
NARRATIVE
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LPA observed licensee and her assistant have current CPR and First Aid certification. Licensee’s expires 09/28/2020 and assistant's on 05/26/2021. LPA did not observe a current roster of the children. LPA observed a fire and disaster drill log which was last completed on 08/01/2019. LPA reviewed nine children's files. LPA observed child 1, 4, 5, 7, 9 and 10 are missing immunization records or are not updated. Child 8 and 10 is missing LIC627. Child 10 is missing entire file. Licensee states day care is not insured. LPA discussed SB792 Immunization Requirements and observed licensee and her assistant have immunization against pertussis, measles and influenza on file.


Supervision of children was discussed with licensee and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. Licensee understands her capacity options and she understands that she cannot have more than 14 children in the home at any time. Licensee understands if she transports children via vehicle, children cannot be left in parked vehicles unattended at any time.

LPA discussed Zero Tolerance with $500 immediate civil penalty. An ongoing $100 per day per violation continues until the violation(s) is corrected. LPA discussed the requirements of AB633 to licensee and provided her the AB633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and licensee understands the requirements. Incidental Medical Services were discussed with the licensee. The licensee is not providing IMS (Incidental Medical Services) 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 reminded the Licensee that effective January 1, 2019 Assembly Bill 2370 requires that all licensed homes to share information on the risks and effects of lead exposure with enrolling and re-enrolling families. LPA provided a copy of the “Lead Poisoning Facts Information Flyer” to the Licensee. Safe sleep information & handout was also discussed with the Licensee.


The following type A and B deficiencies were cited on the attached page (809-D). Appeal rights were provided to the Licensee prior to the conclusion of today's inspection. Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction Due Date may result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.

Notice of site visit was issued and must be posted for 30 days.

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2020
LIC809 (FAS) - (06/04)
Page: 2 of 7
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: GAETA, ABELICIA
FACILITY NUMBER: 434410468
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/22/2020
Section Cited

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102417(g)(4) Operation of a Family Child Care Home. Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger to children shall be stored where they are inaccessible to children.
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This requirement was not met as evidenced by LPA observed shampoo and conditioner accessible to children in shower of bathroom used by children.This poses an immediate risk to the Health, Safety or Personal Rights to children in care.
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Type A
01/22/2020
Section Cited

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Every family day care home for children shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.
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This requirement was not met as evidenced by LPA observed a combo smoke and carbon monoxide detector not working in the home. This poses an immediate risk to the Health, Safety or Personal Rights to children in care.
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AB633 Parent Notification is required.
This page shall be provided to all parents of children currently enrolled and any future children being enrolled for the next 12 months per AB633 requirements.
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: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2020
LIC809 (FAS) - (06/04)
Page: 3 of 7
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: GAETA, ABELICIA
FACILITY NUMBER: 434410468
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/22/2020
Section Cited

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Evidence that the small family child care home contains a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshal under Section 1597.45(d) of the Health and Safety Code or evidence that the large family child care home meets the standards established by the State Fire Marshal under Section 1597.46(d) of the Health and Safety Code.
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This requirement was not met as evidenced by LPA observed a combo smoke and carbon monoxide detector not working in the home.This poses an immediate risk to the Health, Safety or Personal Rights to children in care.
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AB633 Parent Notification is required.
This page shall be provided to all parents of children currently enrolled and any future children being enrolled for the next 12 months per AB633 requirements.

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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: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2020
LIC809 (FAS) - (06/04)
Page: 4 of 7
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: GAETA, ABELICIA
FACILITY NUMBER: 434410468
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/22/2020
Section Cited

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102417(g)(8) Operation of a Family Child Care Home. All homes shall have a current roster of the children.This requirement was not met as evidenced by LPA did not observe a current roster of the children.
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This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Type B
02/05/2020
Section Cited

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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.
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This requirement was not met as evidenced by Child 8 and 10 is missing LIC627.This poses a potential risk Health, Safety Personal Rights risk to children in care.
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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: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2020
LIC809 (FAS) - (06/04)
Page: 5 of 7
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: GAETA, ABELICIA
FACILITY NUMBER: 434410468
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/22/2020
Section Cited

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102418(g) Immunization. Licensee shall document and maintain each child’s immunizations as long as the child is enrolled. This requirement was not met as evidenced by
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LPA observed child 1, 4, 5, 7, 9 and 10 are missing immunization records or are not updated. This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Type B
02/05/2020
Section Cited

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Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative.
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This requirement was not met as evidenced by LPA observed a 3 month old infant in on limits room after being at facility for over and hour and a half. Licensee did not inform LPA of infant. Licensee did not check on child within the hour and a half LPA was present..This poses a potential risk Health, Safety Personal Rights risk to children in care.
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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: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2020
LIC809 (FAS) - (06/04)
Page: 6 of 7
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: GAETA, ABELICIA
FACILITY NUMBER: 434410468
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/05/2020
Section Cited

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102421(a) Childs Records. The licensee shall maintain, in each child’s record, the signed and dated notice form LIC 995A, Parents Rights Notice.
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This requirement was not met as evidenced by Child 10 is missing entire file. This poses a potential risk Health, Safety Personal Rights risk to children in care.
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Type B
02/05/2020
Section Cited

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102421(b) Childs Records. The licensee shall maintain, in each child’s record, a copy of the emergency information card required in Section 102417(g) (7).
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This requirement was not met as evidenced by Child 10 is missing entire file. This poses a potential risk Health, Safety Personal Rights risk to children in care.
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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: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2020
LIC809 (FAS) - (06/04)
Page: 7 of 7