434411142-9-16-2021-07-CC-DVIA-C6WRWM-20210916132323

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434411142
Report Date: 09/16/2021
Date Signed: 09/16/2021 01:23:27 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:	CEBALLOS, DORA		FACILITY NUMBER:	434411142
ADMINISTRATOR:	CEBALLOS, DORA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 876-3794
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95111
CAPACITY:	14	CENSUS: 4	DATE:	09/16/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Dora Ceballos		TIME COMPLETED:	01:30 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	Licensing Program Analyst (LPA) Deanna Villagrana met with licensee Dora Ceballos for a required one year visit. LPA explained the nature of today’s inspection to her. Present were licensee, licensee's brother and four day care children. Days and hours of operation are Monday to Friday, 6:00am to 5:30pm. The adults that reside in the home are licensee and her brother. Licensee states adult daughter comes home on the weekends from college out of town. A review of staff records on 08/17/2021 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 barricaded fireplace in the home. LPA observed a wall heater that was not barricaded. Licensee states it is not working and has someone coming this weekend to repair it. She stated the barricade was taken down to allow repair person to look at it. LPA observed the pilot was not lit. LPA observed safe and sufficient materials, toys, and play equipment for the day care children. All sharp objects, detergents, cleaning compounds, medications, poisons, and other similar items inside the home are stored inaccessible to children. LPA observed a fully charged 3A40BC fire extinguisher. LPA observed a working smoke detector and a working carbon monoxide detector. Licensee states there are no weapons/firearms in the home. Off limit areas indoor: three bedrooms and attached garage. There are no bodies of water. Backyard is fenced. Off limits outdoor: fenced off area surrounding the play area for children including a storage. Licensee states there are no animals in the home. LPA observed licensee and her brother have current CPR and First Aid certification. Licensee’s expires 08/14/2022 and her brother's on 1010/2022. Licensee and her brother have completed Mandated Reporter training.

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna Villagrana	TELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

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: CEBALLOS, DORA	FACILITY NUMBER: 434411142
	VISIT DATE: 09/16/2021

NARRATIVE

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LPA observed a current roster of the children and a fire and disaster drill log which was last completed on 08/16/2021. LPA reviewed four children's files and observed all forms are completed and children have current immunization records. LPA observed day care is insured with Chubb insurance. LPA discussed SB792 Immunization Requirements and observed licensee and her brother's immunization records are 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.

Safe sleep update: LPA discussed the new “Safe Sleep” regulations with the Licensee including the Individual Infant Sleeping Plan (LIC 9227) form to the Licensee. LPA reminded the Licensee that infants up to 12 months of age must sleep on their backs, and all infants shall be supervised while they are sleeping, and documentation of sleep checks must be kept in each infant’s file. Infants shall not be swaddled. There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard. Cribs or play yards shall be free of loose articles and objects.

LPA discussed Zero Tolerance related regulations with licensee Dora Ceballos and was advised of the assessment of $500 immediate civil penalty and an ongoing $100 per day per violation continues until the violation(s) is corrected. 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.

No deficiency was cited.

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

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna Villagrana	TELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

LIC809 (FAS) - (06/04)

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