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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434411131
Report Date: 06/01/2022
Date Signed: 06/01/2022 12:29:34 PM

Document Has Been Signed on 06/01/2022 12:29 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:VELAZQUEZ-RAMIREZ, MAURAFACILITY NUMBER:
434411131
ADMINISTRATOR:RAMIREZ, MAURAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 292-8517
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
06/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Maura Velazquez-RamirezTIME COMPLETED:
12:40 PM
NARRATIVE
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On 06/01/2022 at 09:00 AM, Licensing Program Analyst (LPA) Susy Cervantes met with licensee, Maura Velazquez-Ramirez, for an annual inspection and explained the reason for the visit to them. Present during today's visit were licensee, their son and daughter with 11 children: 8 preschool and 3 infants. Adults living in the home are licensee, their spouse, their son, and daughter with one child age 8 months. Days and hours of operation are Monday through Friday 6:30 AM to 5:30 PM.

A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 05/17/2022 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 covered fireplace, no wall heater, no stairs, and no bodies of water. Licensee stated there are no weapons. Licensee stated they have a dog and they are vaccinated. LPA observed a fully charged 3A40BC fire extinguisher. Carbon Monoxide detector and smoke detectors were operable. Sharp objects, medicines, poisons and cleaning supplies are inaccessible to the children and stored in the top kitchen cabinet. Backyard is fenced. Off limit areas: three bedrooms, one bathroom, garage, and left side of backyard that is fence off.

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 with an aid. Licensee stated they do not 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 06/01/2022 pg. 1/2
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Susy Cervantes
LICENSING EVALUATOR SIGNATURE: DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/01/2022
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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Document Has Been Signed on 06/01/2022 12:29 PM - It Cannot Be Edited


Created By: Susy Cervantes On 06/01/2022 at 11:43 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: VELAZQUEZ-RAMIREZ, MAURA
FACILITY NUMBER: 434411131

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2022

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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Based on record review, the licensee did not comply with the section cited above in which licensee was unable to provide a certificate of completion for Mandated Reporter training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/15/2022
Plan of Correction
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Licensee stated they have taken the class, but have not received the certificate. Licensee will obtain a certificate of completion from the union and will send a copy to SJRO by close of business on June 15, 2022
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 Segura
LICENSING EVALUATOR NAME:Susy Cervantes
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2022


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 06/01/2022 12:29 PM - It Cannot Be Edited


Created By: Susy Cervantes On 06/01/2022 at 11:43 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: VELAZQUEZ-RAMIREZ, MAURA
FACILITY NUMBER: 434411131

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2022

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
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Based on record review, the licensee did not comply with the section cited above in Child 08, 12, and 13 do not have LIC 995A signed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/15/2022
Plan of Correction
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Licensee will obtain parent signatures for form LIC 995A and will submit a copy of the completed form to the San Jose Regional Office (SJRO) by close of business on June 15, 2022

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
LICENSING EVALUATOR NAME:Susy Cervantes
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2022


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 06/01/2022 12:29 PM - It Cannot Be Edited


Created By: Susy Cervantes On 06/01/2022 at 11:43 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: VELAZQUEZ-RAMIREZ, MAURA
FACILITY NUMBER: 434411131

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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Based on record review, the licensee did not comply with the section cited above in which Child 01, 04, and 07 are missing 15 minute sleep logs which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/15/2022
Plan of Correction
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Licensee will create and document infants sleep log and will document sleep every 15 mintues for all infants under 24 months. Licensee will send copies of completed logs to SJRO by close of business on June 15, 2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 Segura
LICENSING EVALUATOR NAME:Susy Cervantes
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2022


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: VELAZQUEZ-RAMIREZ, MAURA
FACILITY NUMBER: 434411131
VISIT DATE: 06/01/2022
NARRATIVE
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Continuation of report dated 06/01/2022 pg. 2/2

LPA took a picture of a current roster of the children. LPA observed a fire and disaster drill log that was last conducted on 04/20/22. LPA reviewed 16 children’s files and observed Child 08, 12, and 13 missing signatures on LIC 995A; Child 08 is missing signatures on LIC 627. Infant individual sleeping plan (LIC 9227) for each infant under 12 months was provided and discussed, LPA observed a completed LIC 9227. 15 minute check sleep log for infants under 24 months was discussed, Child 01, 04, and 07 are missing sleep logs. LPA did not observed that the Licensee and assistant 01 have Mandated Reporter training. Licensee and assistant 01 have Pediatric CPR/1st Aid expiring 04/03/23. Needed documentation for SB 792 which requires immunization against Pertussis, Measles, and Influenza as well as TB testing is on file for licensee and assistants.

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.

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, Maura Velazquez-Ramirez. 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.

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Susy Cervantes
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 06/01/2022 12:29 PM - It Cannot Be Edited


Created By: Susy Cervantes On 06/01/2022 at 12:08 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: VELAZQUEZ-RAMIREZ, MAURA
FACILITY NUMBER: 434411131

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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Based on record review, the licensee did not comply with the section cited above in which Child 08 is missing signatures on LIC 627 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/15/2022
Plan of Correction
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Licensee will obtain signatures on LIC 627 and will submit a copy of completed form to SJRO by close of business on June 15, 2022
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 Segura
LICENSING EVALUATOR NAME:Susy Cervantes
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2022


LIC809 (FAS) - (06/04)
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